
Glass. 
Book. 



COPYRIGHT DEPOSIT 



PRACTICE OF MEDICINE. 



BY 

i 



H. R ARNDT, M. D., 



Formerly Professor of Materia Medica and Therapeutics, and Clinical Professor 
of Nervous Diseases, Homoeopathic Medical College, University of Michigan ; 
Member of the American Institute of Homoeopathy ; Corresponding 
Member of the Massachusetts Homoeopathic Medical Society ; Ex- 
President of the Michigan State Homoeopathic Medical Society, 
of the Western Academy of Homoeopathy, of the Cali- 
fornia State Homoeopathic Medical Society, of the 
Southern California Homoeopathic Medical 
Society ; Editor-in-Chief of Arndt's 
S3 T stem of Medicine ; Editor of 
the Pacific Coast Journal 
of Homoeopath}*, 
etc., etc., etc. 



PHILADELPHIA : 
BOERICKE & TAFEL. 



****** 



29265 



COPYRIGHT 

BY 

BOKRICKK & TAFEL. 

1S99. 









APH101C 



T. B. & H. 1!. COCHRAN, PRINTERS 
LANCASTER, PA. 



V°V3 



I o the JVUmory 

of 

|)r. George William Barnes, 

A pioneer of tl^e [Profession in Southern (California, 

and 

<A Li-oVer of JV| an^nd, 

| his \/olurr|e is Affectionately dedicated. 



PREFACE. 



The purpose, originally entertained, of putting within one 
volume of, not to exceed, one thousand .pages the information 
which the general practitioner and the student of medicine ex- 
pect to find in a work on " Practice " had to be abandoned as 
the work itself took shape. It is hoped that the reader will 
find no waste of space, and will come to the conclusion that 
the volume could not be materially reduced in size without 
also lessening its usefulness. 

The completion of the work has been delayed by impaired 
health and by the difficulties of reading proof set up at a dis- 
tance of three thousand miles. In spite of every precaution a 
few annoying typographical errors have crept into the text. 
Of these, the most serious will be found on page 572. "Affec- 
tions of the Blood-vessels of the Skin" should, of course, read 
" of the Spine." The reader is requested to make the necessary 
correction. 

Acknowledgment for aid rendered in the preparation of the 
manuscript for the printer and in reading proof is due to my 
assistant, Dr. R. de L. Foster. 

H. R. Arndt. 

San Diego, California, January, 1899. 



CONTENTS. 



I. SPECIFIC INFECTIOUS DISEASES. 

Page. 

Typhoid Fever, ' 19 

Typhus Fever, 40 

Relapsing Fever, 45 

Yellow Fever, 49 

Malarial Fever, ... 58 

Intermittent Fever, 60 

Remittent Fever, . : 69 

Pernicious Malarial Fever 72 

Chronic Malarial poisoning, . . , 75 

Dengue Fever, 79 

Diphtheria, 81 

Scarlet Fever, 100 

Measles. 120 

Rubella — Rcetheln, 127 

Variola — Small-Pox, . . 129 

Varioloid, . . 132 

Vaccination, 134 

Varicella — Chicken-Pox, 141 

Epidemic Influenza, 143 

Epidemic Parotitis — Mumps, 151 

Whooping-Cough, 156 

Cerebro-Spinal Meningitis, 163 

Erysipelas, 176 

Septicaemia and Pyaemia, 181 

Anthrax, 186 

Asiatic Cholera, • 189 

Dysentery, 199 

Tuberculosis, 210 

^Etiology, 210 

Acute Miliary Tuberculosis, 216 

Tuberculosis of Lymph-Glands — Scrofulosis, 220 

Pulmonary Tuberculosis, 225 

Laryngeal Tuberculosis, 259 

Tuberculosis of the Serous Membranes, 263 

Tuberculosis of the Alimentary Canal, 265 

Tuberculosis of the Liver, 266 



I CONTENTS. 

Page. 

Tuberculosis of the Genito-Urinary System, 266 

Tuberculosis of the Nervous System 268 

Tuberculosis of the Blood-Vessels 268 

Syphilis 269 

Rabies 291 

Tetanus, 296 

Leprosy, 302 

Glanders, 306 

Actinomycosis 310 

Febricula, 312 

Weil's Disease ... 314 

Mountain Fever, 315 

Sweating Sickness, ■ 316 

Malta Fever, 316 

Milk Fever, 318 

II. CONSTITUTIONAL DISEASES. 

Rheumatic Fever, 323 

Chronic Articular Rheumatism 332 

Muscular Rheumatism, 335 

Gonorrhceal Rheumatism, 33S 

Rheumatic Arthritis— Arthritis Deformans, 340 

Gout, 346 

Diabetes Mellitus, 357 

Diabetes Insipidus, 369 

Rickets 372 

Scurvy 380 

Purpura 385 

Haemophilia, . 389 

III. DISEASES OF THE NERVOUS SVSTEM. 

Mental Diseases, . 393 

General Introduction, 393 

Organic Insanities, 398 

Acute Periencephalitis, 398 

Chronic Periencephalitis, 400 

Constitutional Insanities, 405 

Gouty Insanity, 405 

Epileptic Insanity, 405 

Hysterical Insanity, 406 

Toxaemic Insanity, 406 

Pure Insanities, 406 

Melancholia, 406 

Mania, 410 

Confusional Insanity, 413 

Terminal Dementia, 414 

Neuropathic Insanity, 415 

Paranoia, 418 



CONTENTS. 

Page. 

Periodical Insanity, 421 

Therapeutics of Insanity, 422 

General and Functional Diseases, 428 

Neurasthenia, 428 

Hysteria, 435 

Vertigo, 450 

Epilepsy, "452 

Infantile Convulsions — Eclampsia, 467 

Acute Chorea — St. Vitus's Dance, 472 

Other Affections Characterized by Choreic Movements, .... 480 

Reflex Chorea, .... 480 

Chorea Major, 481 

Electrical Chorea, 481 

Habit Spasms, 481 

Tic Convulsif, 481 

Saltatoric Spasms, 482 

Huntingdon's Chorea, 482 

Rhythmic Chorea, 483 

Tetany, 483 

Paralysis Agitans, 485 

Traumatic Neurosis, ■ 487 

Caisson Disease — Diver's Paralysis, 489 

Occupation Neurosis, 490 

Writer's Cramp, 490 

Migraine — Hemicrania, 492 

Neuralgia, 496 

Neuralgia of the Trigeminus, 497 

Cervico-Occipital Neuralgia, 498 

Cervico-Brachial Neuralgia, 498 

Neuralgia of the Phrenic Nerve, 498 

Intercostal Neuralgia, ... 499 

Mastodynia, 499 

Lumbar Neuralgia, 499 

Coccydinia, 499 

Sciatic Neuralgia, 500 

Neuralgia of the Nerves of the Feet, 501 

Treatment of Neuralgia, 501 

Sleep and Some of its Disorders, 507 

Insomnia, 509 

Hypnotics, 512 

Narcolepsy, 513 

Somnambulism, 514 

Organic Diseases of the Brain, 516 

Affections of the Meninges, 516 

Pachymeningitis, 516 

Leptomeningitis, 517 

Acute Meningitis, 517 

Tubercular Meningitis, 522 



CONTENTS. 

Page. 

Chronic Leptomeningitis, 525 

Therapeutics of Meningitis, 525 

Disorders of the Cerebral Circulation, 528 

Cerebral Anaemia, 528 

CEdema of the Brain, 529 

Cerebral Hyperaemia 529 

Dis%ases of the Blood- Vessels of the Brain, 530 

Cerebral Haemorrhage, 530 

Cerebral Embolism and Thrombosis — Softening, 541 

Occlusion of the Carotid, 543 

Occlusion of the Vertebral Artery, . 543 

Occlusion of the Basilar Artery, 543 

Occlusion of the Anterior Cerebral Artery, 543 

Occlusion of the Middle Cerebral Artery, 543 

Occlusion of the Posterior Cerebral Artery, 544 

Cerebral Aneurism, 544 

Thrombosis of the Cerebral Sinuses, 545 

Aphasia, '. 546 

Cerebral Palsies of Children, 549 

Hemiplegia, 549 

Spastic Diplegia, 551 

Insular Sclerosis of the Brain 552 

Inflammation of the Brain, 554 

Tumors of the Brain, 556 

Chronic Hydrocephalus, 561 

Infantile Hydrocephalus, 561 

Hydrocephalus of Adults, 562 

Diseases of the Spinal Cord, 563 

General Notes on Focal Lesions in the Cord 563 

Notes on the Reflexes, 567 

Acute Spinal Meningitis, 568 

Chronic Spinal Meningitis, 571 

Affections of the Blood-Vessels of the Spine, 572 

Acute Affections of the Spinal Cord, 573 

Acute Myelitis, 573 

Myelitis of the Anterior Horns, 577 

Treatment of Acute Myelitis and Infantile Paralysis, . . . 581 

Acute Ascending (Landry's) Paralysis, 584 

Chronic Diseases of the Spinal Cord, 585 

Spastic Paraplegia, 585 

Secondary Spastic Paralysis, 587 

Paraplegia of Infants, 587 

Ataxic Paraplegia, . 588 

Primary Combined Sclerosis, 588 

Locomotor Ataxia 589 

Hereditary I Friedreich's) Ataxia 599 

Syringo-Myelia, 6or 

Compression Myelitis, 602 



CONTENTS. 

Page. 

Lesions of the Cauda Equina and Conus Medullaris, 605 

Tumors of the Spinal Cord and its Membranes, 605 

Progressive Spinal Muscular Atrophy, 606 

Bulbar Paralysis, 609 

Diseases of the Nerves, 611 

Neuritis, 611 

Localized Neuritis, 611 

Multiple Neuritis, 612 

Alcoholic Neuritis, 614 

Post-Febrile Neuritis, 615 

Endemic Neuritis — Beri-beri 615 

Neuroma, 61S 

Diseases of the Cranial Nerves, 619 

Diseases of the Olfactory Nerve, 619 

Diseases of the Optic Nerve, 620 

Lesions of the Retina, 620 

Lesions of the Optic Nerve, 621 

Lesions of the Chiasm and Tract, 622 

Affections of the Motor Nerves of the Eye, 623 

Affections of the Third Nerve, 623 

Affections of the Fourth Nerve, 624 

Affections of the Sixth Nerve, 624 

Ophthalmoplegia, 625 

Spasm of the Ocular Muscles, 626 

Lesions of the Fifth Nerve, 626 

Lesions of the Facial Nerve, 627 

Bell's Paralysis, 627 

Spasm, 629 

Auditory Nerve, 630 

Meniere's Disease, 631 

Glosso-Pharyngeal Nerve, 632 

Pneumogastric Nerve, 633 

Spinal Accessory Nerve, 63s 

Wry-neck, 635 

Hypoglossal Nerve, 636 

Diseases of the Spinal Nerves, . 637 

Cervical Plexus, 637 

Brachial Plexus, 639 

Lumbar and Sacral Plexus, 641 

Vaso-Motor and Trophic Disorders, 642 

Raynaud's Disease, 642 

Angio-Neurotic Qjdema, 644 

Acromegaly, 645 

Scleroderma, 646 

Sclerema neonatorum, 647 

Oedema neonatorum, 647 

Sclerodactylia, 647 

Ainhum, 648 

Facial Hemiatrophy, 648 



CONTEXTS. 

IV. DISEASES OF THE MUSCLES. 

Page. 

Myositis, 651 

Progressive Muscular Atrophy, 652 

Juvenile Form of Erb, .... 652 

Infantile Type of Duchenne, 654 

Peroneal Type of Muscular Atrophy 655 

Thomsen's Disease 656 

Paramyoclonus Multiplex 657 

V. INTOXICATIONS, HEAT-EXHAUSTION, OBESITY. 

Alcoholism 661 

Lead-Poisoning 667 

Morphinism 671 

Cocainism 674 

Arsenical Poisoning 674 

Ptomaine-Poisoning 676 

Heat-Exhaustion, . 679 

Heat-Exhaustion 679 

Thermic Fever — Sun-Stroke, . 680 

Obesity 685 

VI. DISEASES OF THE DIGESTIVE ORGANS. 

Diseases of the Mouth 691 

Stomatitis, 691 

Catarrhal Stomatitis 691 

Aphthous Stomatitis, 692 

Parasitic Stomatitis 693 

Ulcerative Stomatitis, 695 

Gangrenous Stomatitis, 696 

Treatment of Stomatitis, 698 

Diseases of the Tongue 701 

Glossitis, 701 

Simple Ulceration 703 

Diseases of the Salivary Glands, 704 

Ptyalism 704 

Xerostomia 704 

Inflammation, 704 

Diseases of the Pharynx, 705 

Acute Catarrhal Pharyngitis, 705 

Chronic Catarrhal Pharyngitis 706 

Follicular Pharyngitis, 708 

Therapeutics of Pharyngitis, 711 

Ulceration of the Pharynx, 716 

Herpetic Pharyngitis 717 

Phlegmonous Pharyngitis, 721 

Acute Infectious Phlegmonous Pharyngitis, 724 

Erysipelatous Pharyngitis 724 

Gangrenous Pharyngitis 725 



CONTENTS. 3 

Page. 

Retro-Pharyngeal Abscess, 726 

Angina Uudovici, 72S 

Diseases of the Tonsils, 729 

Acute Tonsillitis, . 729 

Chronic Tonsillitis, 734 

Diseases of the Oesophagus, ... 740 

Oesophagitis, . 740 

Stricture of the Oesophagus, 742 

Dilatation of the Oesophagus, 745 

Rupture and Perforation, 746 

Morbid Growths — Cancer, 747 

Neuroses of the Oesophagus, 749 

Spasm, . . 749 

Diseases of the Stomach, 754 

Acute Gastric Catarrh, 754 

Chronic Gastric Catarrh, 761 

Neuroses, 767 

Gastralgia, 767 

Nervous Dyspepsia, . . 769 

Nervous Vomiting, " 772 

Peristaltic Unrest, 772 

Rumination of Food, 773 

Treatment of Neuroses, 773 

Dilatation of the Stomach, 781 

Simple Ulcer, 785 

Cancer, 794 

Haemorrhage, 802 

Miscellaneous Affections, S06 

Stenosis of the Cardiac Orifice, 806 

Stenosis of the Pyloric Orifice, 807 

Cirrhosis of the Stomach, 807 

Gastromalacia, 808 

Atrophy, 809 

Abscess in the Wall of the Stomach, ... 809 

Albuminoid Disease, 809 

Tubercle of the Stomach, 809 

Perforation, 810 

Rupture, 810 

Diseases of the Intestines, 8 to 

Catarrhal Enteritis — Diarrhoea, 810 

Acute Catarrhal Enteritis, 812 

Cholera Morbus, 813 

Chronic Catarrhal Enteritis, 814 

Enteritis in Children, 826 

Acute Dyspeptic Diarrhoea, 828 

Cholera Infantum, 829 

Acute Entero-Colitis, 830 

Chronic Diarrhoea of Children, 8^2 



CONTENTS. 

Page. 

Appendicitis, 842 

Intestinal Obstruction, 852 

Constipation SSi 

Enteralgia — Intestinal Colic, . S67 

Miscellaneous Affections of the Intestines, S72 

Ulceration, 872 

Haemorrhage, 874 

Cancer, 875 

Amyloid Degeneration, S77 

Affections of the Mesentery 878 

Diseases of the Liver, 878 

Congestion of the Liver, 878 

Perihepatitis 881 

Acute Parenchymatous Hepatitis — Yellow Atrophy, 883 

Suppurative Hepatitis — Abscess of the Liver, . . 885 

Fibrous Hepatitis — Cirrhosis of the Liver 890 

Fatty Liver, . 896 

Amyloid Liver, 897 

Morbid Growths, 898 

Cancer 898 

Simple Cysts, 902 

Erectile Tumors, 902 

Lymphatic Formations, 902 

Tubercles, 902 

Malformation and Malposition, 903 

Movable Liver, 903 

Diseases of the Gall-Ducts and Gall-Bladder, 904 

Catarrhal Jaundice 904 

Cholelithiasis 908 

Biliary Colic 909 

Miscellaneous Affections, 914 

Cancer of the Gall-Ducts, 914 

Cancer of the Gall-Bladder 914 

Obstruction 914 

Diseases of the Blood-vessels of the Liver, . 915 

Diseases of the Pancreas, 917 

Acute Pancreatitis 917 

Acute Hemorrhagic Pancreatitis, . . 91S 

Acute Grangrenous Pancreatitis 919 

Acute Suppurative Pancreatitis, . .919 

Chronic Pancreatitis 920 

Cancer of the Pancreas 921 

Pancreatic Cysts, 922 

Pancreatic Calculi, 923 

Diseases of the Peritonaeum 924 

Acute Peritonitis, 924 

Chronic Peritonitis, 931 

Tubercular Peritonitis, 932 



CONTENTS. XV 

Page. 

Cancer of the Peritonaeum, 937 

Ascites 938 

VII. DISEASES OF THE RESPIRATORY SYSTEM. 

Diseases of the Nose, 945 

Acute Nasal Catarrh, 945 

Chronic Nasal Catarrh, 947 

Hay-Fever, . . • 952 

Epistaxis, 955 

Diseases of the Larynx, 956 

Acute Laryngitis, 956 

Submucous Laryngitis, 958 

Laryngitis Stridulus, 959 

Chronic Laryngitis, 961 

©Edematous Laryngitis, 964 

Laryngismus Stridtilus, 966 

Pseudo-Membranous Laryngitis, .... 968 

Syphilitic Laryngitis, 974 

Diseases of the Bronchi, 976 

Acute Bronchitis, 976 

Chronic Bronchitis, 981 

Fibrinous Bronchitis, 986 

Bronchiectasis, 988 

Bronchial Asthma, , 989 

Diseases of the Parenchyma of the Lungs, 993 

Disturbances of Circulation in the Lungs, 993 

Pulmonary Congestion, 993 

Pulmonary Qjdema, 994 

Pulmonary Haemorrhage, 994 

Pulmonary Apoplexy, 996 

Pneumonia, 998 

Chronic Interstitial Pneumonia, 1008 

Broncho-Pneumonia — Capillary Bronchitis, 1010 

Emphysema, 1016 

Abscess of the Lung, 1019 

Gangrene of the Lung, 1020 

Cancer (New Growth) of the Lung, 1022 

Diseases of the Pleura, 1023 

Acute Pleurisy, . . 1023 

Dry, Plastic Pleurisy, ... 1024 

Sero-Fibrinous Pleurisy, ... 1024 

Purulent Pleurisy — Empyema, 1029 

Haemorrhagic Pleurisy, 1032 

Other Varieties of Pleurisy, 1032 

Chronic Pleurisy, 1033 

Hydrothorax, 1036 

Pneumothorax, 1037 



1 CONTENTS. 

Page. 

Diseases of the Mediastinum, 1039 

Mediastinitis 1039 

Acute Lymphadenitis, 1040 

Morbid Growths, 1040 

Abscess of the Mediastinum, 1042 

Emphysema of the Mediastinum, 1043 

Other Affections 1043 

VIII. DISEASES OF THE ORGANS OF CIRCULATION. 

Diseases of the Pericardium, 1047 

Pericarditis, 1047 

Acute Plastic Pericarditis, 1047 

Pericarditis with Effusion, 1049 

Chronic Adhesive Pericarditis, 1055 

Hydropericardium, 1056 

Haemopericardium 1057 

Pneumopericardium 1057 

Diseases of the Heart, 1057 

Diseases of the Endocardium, 1057 

Endocarditis 1057 

Acute or Simple Endocarditis, 1058 

Malignant Endocarditis 1060 

Chronic Endocarditis — Chronic Valvular Lesions, 1065 

Mitral Insufficiency, 1066 

Mitral Stenosis, 1070 

Aortic Insufficiency, 1072 

Aortic Stenosis, 1076 

Tricuspid Insufficiency, 1077 

Tricuspid Stenosis 1078 

Pulmonary- Insufficiency, 1079 

Pulmonary Stenosis 1079 

Symptomatology of Valvular Disease, 1079 

Treatment of Valvular Disease, 1085 

Hypertrophy of the Heart, 1092 

Dilatation of the Heart, 1096 

Diseases of the Myocardium, 1098 

Atrophy of the Heart, 1098 

Acute Myocarditis 1099 

Chronic Myocarditis, 1102 

Degenerations of the Myocardium, 1 104 

Parenchymatous Degeneration, 1104 

Fatty Degeneration . 1105 

Aneurism of the Heart, 1 107 

Rupture of the Heart, 1108 

Tumors of the Heart, 1109 

Neuroses of the Heart, ... 11 10 

Palpitation mo 

Tachycardia — Rapid Heart, it n 

Arrhvthmia — Irregular Heart, 11 18 



CONTENTS. XY11 

Page. 

Bradycardia — Slow Heart, 1119 

Angina Pectoris, 1120 

Diseases of the Blood-Vessels, 11 26 

Diseases of the Arteries, 1126 

Acute Arteritis, 11 26 

Arterio-Sclerosis, 11 26 

Aneurism, 1132 

Aneurism of the Thoracic Artery, 1134 

Aneurism of the Pulmonary Artery, 1 142 

Aneurism of the Coronary Artery, 1 143 

Aneurism of the Abdominal Artery, 1143 

Stenosis of the Aorta, 1144 

Rupture of the Aorta, 1145 

Diseases of the Veins, 1145 

Phlebitis, . 1145 

Dilatation of the Veins, 1148 

i IX. DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

Anaemia, H53 

Secondary Anaemia, 1 153 

Primary or Essential Anaemia, 1154 

Chlorosis, 1154 

Progressive Pernicious Anaemia, 1161 

Leukaemia, 1164 

Pseudo-Leukaemia or Hodgkin's Disease, 11 69 

Addison's Disease, . 1173 

Diseases of the Thyroid Gland, 11 76 

Goitre, 1176 

Exophthalmic Goitre, 1179 

Myxcedema, 1184 

X. DISEASES OF THE KIDNEYS AND BLADDER. 

Movable Kidney, 1189 

Congestion of the Kidneys, 1192 

Anomalies of the Urine, , . . 1193 

Anuria, TI 93 

Haematuria, 1193 

Haemoglobinuria, 1196 

Albuminuria, 1197 

Pyuria, 1201 

Chyluria or Galacturia, 1201 

Lipuria or Adiposuria, 1202 

Lithuria, 1202 

Oxaluria, 1203 

Cystinuria, 1203 

Phosphaturia, • . . . . 1203 

Urobilinuria, 1204 

Indicanuria, 1204 

Melanuria, 1205 



XV111 CONTEXTS. 

Page. 

Acetonuria 1205 

Diaceturia 1206 

Alkaptenuria, 1206 

Casts in the Urine 1206 

Uraemia, . 1207 

Acute Bright's Disease 121 1 

Chronic Bright's Disease 1220 

Chronic Parenchymatous Nephritis 1220 

Chronic Interstitial Nephritis, 1225 

Amyloid Disease 1231 

Pyelitis 1233 

Hydronephrosis, 1236 

Nephrolithiasis, 1239 

Tumors of the Kidneys, 1245 

Cysts of the Kidneys 1247 

Perinephric Abscess, 1248 

Diseases of the Bladder 1250 

Cystitis, 1250 

Enuresis — Incontinence, 1257 

XI. DISEASES DUE TO ANIMAL PARASITES. 

Psorospermiasis, 1264 

Helminthiasis, 1265 

Tape-worms, 1265 

Cysticercus Disease, 1269 

Echinococcus Disease — Hydatid Disease, 1270 

Fluke-Disease, 1274 

Ascariasis, 1276 

Anchylostomiasis 1278 

Filiariasis 1280 

Trichinosis 1281 

Diseases due to Parasitic Insects, 1285 

Itch .1285 

Pediculosis, 1287 

( Cimex lectularius), 1288 

(Pulex irritans) 1288 

( Pulex penetrans ) 1288 

Myasis, 1289 



PART I 



SPECIFIC INFECTIOUS DISEASES. 



PART I. 

SPECIFIC INFECTIOUS DISEASES. 



TYPHOID FEVER. 

(Enteric Fever; Typhus Abdominalis; Ileo-typhus.) 

Description and Causation. — Typhoid fever occurs chiefly 
in temperate climates, especially during the months of August, 
September and October, when the weather is hot and dry and 
the ground-water low. Young people are more frequently the 
victims. About one-half of the cases occur from fifteen to 
twenty-five years of age. After the age of thirty the liability 
to this fever grows rapidly less, and at fifty it practically 
ceases. However, the quite young and the aged may be at- 
tacked by it. If found in the extremes of life, the disease, 
though terminating fatally, may escape recognition, being 
covered up by the symptoms of such complications as are 
usual at this time of life. Congenital cases are known to have 
occurred, the mother having had the fever late during her 
pregnancy. One attack generally, though by no means always, 
insures immunity from subsequent seizures. 

The specific cause of typhoid fever is the typhoid-bacillus 
(Koch-Eberth), "a short, thick rod with rounded ends, three 
times as long as broad, rendered easily visible by saturated 
solutions of methylene blue. Vacuoles in the ends of the vessels 
are taken for spores" (Whittaker). A chemical agent, typho- 
toxine, has been extracted, which, injected, becomes a source of 
specific infection, causing typhoid fever. The bacillus is de- 
stroyed by heat, lives in drinking water from seven to fourteen 
days, and in sewage, dung-hills, etc., for a period not exceeding 
three months. In the infected human body it is found in 
colonies in the intestinal lymphoid tissue, mesenteric glands, 
spleen, liver, stool, blood, urine, meninges and, it is claimed, 
even in the blood of the foetus. 



20 SPECIFIC INFECTIOUS DISEASES. 

The disease, almost always, is conveyed by the use of con- 
taminated drinking water from wells, springs or reservoirs, 
into which have emptied or filtered dejecta containing the spe- 
cific bacillus. This has been demonstrated beyond the possi- 
bility of doubt. Milk, diluted with water containing the typhoid 
bacillus or carried in cans rinsed with similarly impure w r ater, 
has thus become an effective carrier of the disease. Petten- 
koffer maintains that the ground-soil is the breeder of the 
bacillus; that the soil made up of alluvial and detrital deposits, 
i. e., soil easily penetrated by air and water, is favorable to 
the development of the specific poison and to the spread of the 
disease, while heavy, firm, rocky soil renders its development 
and spread impossible. Pettenkoffer and his followers insist 
that certain changes in the soil are necessary before infection 
becomes possible; that the ground air, rising, carries the infec- 
tion into the atmosphere and into the houses, where it is in- 
haled; they- have also shown that when water stands high in 
the ground, the disease is restricted; that when it stands low, 
cases occur with much greater frequency. The effect of the dif- 
ferent kinds of ground-soil upon the development of the bacil- 
lus, it is maintained with considerable show of justice, also ex- 
plains why during epidemics certain streets or parts of a town 
are heavily afflicted, while others almost wholly escape. 

Further observation will undoubtedly prove that there is 
more than one mode of infection, and conveyance of the disease 
germs by means of the air inhaled will be shown to be common. 
In all cases, however, individual susceptibility plays an import- 
ant role in the spread of this, and every other, infectious disease, 
some persons, constantly- exposed to the infection, remaining 
well, while others, though equally robust, easily fall a victim 
under exposure to the same agent. 

That an element of contagion exists in typhoid fever seems 
established from the fact that nurses and others — as domestics 
or laundrymen who handle the body linen of persons sick with 
ty-phoid fever — quite commonly succumb to the fever. 

Symptomatology. — In the vast majority of cases the period 
of incubation is more or less protracted, extending from a few 
days to two, or more, weeks, and in exceptional cases even 
longer. The patient complains of remarkable prostration, in- 
disposition, lassitude and inability- to discharge the common 



TYPHOID FEVER. 21 

duties of life. There is present a severe, distressing headache, 
with bad taste in the mouth, loss of appetite, shivering, some- 
times followed by slight fever, aching all over, especially in the 
arms and legs, and often repeated and copious bleeding at the 
nose. The prostration and general condition becoming worse, 
the patient is obliged to go to bed, and the case passes into the 
care of a physician. During the first week in bed the symptom 
which attracts most attention is the characteristic fever, the 
bodily temperature rising steadily from one and one-half de- 
grees each day until at the end of the week a temperature of 
103° to 104° is reached. The pathognomonic "step-ladder" 
ascent of the temperature curve is due to the thermometer in 
the evening (4to8 p.m.) registering one or one and one-half 
degrees higher than in the morning (4 to 8 a. m.) of the same 
day, the morning temperature of successive days showing the 
same gain, giving a daily, distinct remission. The pulse, in the 
meantime ranges from 100 to 110, is rather heavy, full, but of 
low tension, not uncommonly dicrotic. If the fever is excep- 
tionally high, delirium, especially at night, may be present; if 
so, it is likely to be a low, muttering delirium. In the average 
case, however, the very stubborn and painful headache, which 
has continued, and which may continue for weeks to come, is 
accompanied with a confused state of mind and great apathy, 
the patient, even at this early stage of the disease, betraying a 
tendency to that perfect indifference to all externals, and even 
to his own condition, which is marked in the so-called typhoid 
state. The coating of the tongue has become thick and white, 
though a reasonable degree of moisture may still be present. 
Tenderness and distension of the abdomen are noted. Diar- 
rhoeic stools, two or three times daily, of grayish-brown ap- 
pearance ("pea-soup" diarrhoea), frequently very offensive, 
occur; in rare cases constipation exists, and in exceptional 
cases may continue throughout the course of the disease. 
Later, splenic enlargement shows itself, and usually at the end 
of the first week, sometimes not until the tenth day, the char- 
acteristic rash appears. More commonly this rash — rose- 
colored, slightly raised, disappearing under pressure, but re- 
turning promptly when the pressure is removed — is first seen 
on the abdomen; other parts of the body may also show it, as 
the lower chest, back, arms, legs, etc. The urine is dark-colored 
and scanty. 



22 SPECIFIC INFECTIOUS DISEASES. 

The second week of the disease, if the case proves an excep- 
tionally light one, sees a decrease in the fever, with, possibly, a 
return of normal temperature at its close. Such cases, how- 
ever, are comparatively rare, though often the indicated remedy 
does excellent work, aborting attacks which threatened to be 
persistent and violent. Usually the fever remains continuously 
high, the morning remissions being very slight or disappearing 
entirely. The expression of the face has become heavy, stupid 
and listless ; the tongue and lips are dry. The abdominal symp- 
toms steadily increase in severity, diarrhoea, tympanitis and 
tenderness being well pronounced and in some cases increasing 
daily. The pulse is less full, quick, comparatively light, no 
longer dicrotic. The so-called "typhoid state" becomes more 
marked : slight notice is taken of what is transpiring in the 
room : the intense headache is endured without complaint ; 
though parched with thirst, the sick one does not ask for drink, 
but appears utterly indifferent to everything. 

Death at this time may result from the profound depression 
of the nervous S3 r stem, from profuse haemorrhage, or from per- 
foration. 

The third week may witness an improvement in the general 
condition of the case. If so, the fever and temperature are 
lowered and the morning remissions pronounced ; the tone of 
the nervous system is better and the apathy less profound. 
Many of the special sj^mptoms, as the abdominal symptoms, 
may remain threatening. Under the most encouraging condi- 
tions the patient suffers much from weakness ; the great waste 
which has been going on, with the lack of nourishment, explains 
the exhaustion and loss of flesh which are apparent at this 
time even in the most favorable cases. 

Should the typhoid state become more pronounced, the delir 
ium grows more constant, possibly more violent, unsteadiness 
of motion and muscular tremors show themselves, pulmonary 
or cardiac involvement set in, and the sphincters become re- 
laxed. There is now special danger from haemorrhage and per- 
foration. 

The fourth week is likely to witness a decided change. If for 
the better, the general tone of the patient improves. The tem- 
perature lowers and within a few days becomes normal ; with 
it, the delirium subsides and the mental condition improves, 



TYPHOID FEVER. 23 

sometimes quickly and to a remarkable degree; the tongue 
clears off, and there is a desire for food ; the diarrhoea also 
grows better and may disappear -within a few days. If the 
change is for the worse, all the symptoms grow in severity ; the 
fever remains continuously high, the pulse becomes thread-like, 
the face expresses extreme prostration of the vital forces ; the 
lips and tongue are dry, brown, fissured, at times ulcerated ; 
the lips and teeth are covered -with sordes ; the jaw drops ; de- 
lirium of a low character is constant; faeces and urine are 
passed involuntarily and unconsciously ; the patient picks at the 
bed-clothes, grasps imaginary objects, and slides down in the 
bed ; fetor from the mouth may be very offensive ; the urinary 
secretion in most cases is very scanty, and tympanitis exces- 
sive. At this time the chief danger to life arises from secondary 
complications ; heart failure here is common. 

The fourth week safely passed, the average case convalesces 
by lysis, yet fever may continue for an indefinite period, some- 
times for several weeks. There is danger of relapse or recrudes- 
ence of the fever and of complications. Recovery is always 
slow. Unusual care must be taken to guard the patient against 
over-exertion, over-eating, or exposure. 

Special Symptoms. — The onset of typhoid fever is not 
always as insidious as described. Sometimes severe pulmonary 
symptoms appear first, a true lobar pneumonia developing, 
with typhoid symptoms following later and unexpected; or 
a bronchial catarrh may be so pronounced as to seriously em- 
barrass the diagnosis. Or the gastric symptoms which so com- 
monly accompany the prodromal stage may be sufficiently 
violent to throw off his guard even an experienced diagnosti- 
cian. Or the medical man may not be consulted at once ; this 
often happens when the patient is determined to overcome by 
his own exertion the malaise and sense of exhaustion from 
-which he suffers. In such cases, when the vital forces finally 
and suddenly yield, high fever and violent, even maniacal, 
delirium may be the first sjmiptoms which present themselves 
to the physician. Again, we may find the so-called "ambula- 
tory" form of the disease, the case dragging along a slow, 
leisurely course, and the patient presuming that he is merely suf- 
fering from malarial poisoning. It is not unusual in the latter 
form to find on the first visit a temperature of 104° and a well- 
developed rash. 



24 SPECIFIC INFECTIOUS DISEASES. 

Much less rare among the early modifications and complica- 
tions are acute nephritis, meningitis and, in very exceptional 
cases, haemorrhage or perforation. 

Fever — Typhoid fever is often divided into weeks: "First, a 
week of ascent; second, the two weeks of continuous eleva- 
tion ; third, the week of marked remission up to the conclusion 
of the disease. The weeks correspond quite closely to the ana- 
tomical lesions in the intestinal canal. During the first week 
the glands and follicles are in a state of hyperemia ; during the 
second week there is associated tumefaction ; during the third 
week the glands slough; during the fourth week they cica- 
trize." ( YVhittaker. ) The fever thus is largely governed by the 
local intestinal lesion and its development; characteristic 
temperature curve has been pointed out, as well as its remit- 
tancy, the average difference between evening and morning 
temperature being from three to four degrees. 

Variations occur. In certain cases, marked by the sudden 
onset of a heavy chill, the temperature may at once rise to 
103°, or more. A favorable turn in the course of the disease 
ma}' produce a ready return to normal within the second week. 
Or, during convalescence, a trifling exertion, some slight indis- 
cretion, may send up the temperature, and keep it high for 
several days, then returning to normal ; no anxiety need be felt 
at such a time if the general state of the patient undergoes no 
change for the worse. If, however, during the latter part of 
the third week, in spite of a normal morning and day tempera- 
ture, a persistent and continuous rise is observed in the even- 
ing, the- possibility' is that complications exist — as marked 
anaemia — which should be carefully watched. 

A very high temperature is suspicious : hyperpyrexia with a 
register of 106° is a dangerous sign, usually denoting approach- 
ing death. A sudden drop in the temperature to sub-normal 
indicates internal haemorrhage, even before the blood appears 
in the stool, and is a grave symptom. 

Generally speaking, it must be remembered that very nervous 
people in whom the constitutional symptoms may give no 
cause for anxiety, may still have a comparatively high tempera- 
ture. Exceptional cases have been put on record in which all 
the pathognomonic constitutional symptoms were present, 
while no fever existed (afebrile type). The pulse during con- 
valescence is often remarkablv slow. 



TYPHOID FEVER. 25 

Gastro-Intestinal Symptoms. — The appearance of the 
tongue has been described; the throat (fauces) is sometimes 
much congested, and catarrhal pharyngitis of moderate severity 
may exist. Should extensive membranous deposits occur in 
the pharynx during the latter part of the disease, an unfavor- 
able termination of the case is probable. The gastric symp- 
toms vary in intensity. Vomiting, in exceptional cases, may 
itself become a dangerous complication, death through exhaus- 
tion having resulted from it. During the third, and even 
second, week gastric ulceration may develop. 

Diarrhoea is common ; it is usually catarrhal and persists for 
the first two weeks ; sometimes it appears later in the course 
of the disease. Blood is often seen in the stool by the aid of 
the microscope, but the term "bloody stool" is not used save 
when the naked eye detects it. The stools are offensive, alka- 
line and, upon standing, separate into a thin serous layer and 
a sediment which contains remnants of food, debris, triple 
phosphate crystals, possibly blood and, later, sloughs of gland- 
ular structure and intestinal tissue. Haemorrhage is not un- 
common ; it occurs in three to five per cent of all cases ; while 
always a serious symptom, it does not of itself determine a 
fatal issue. If the bleeding is from intense hyperaemia, which 
may find also relief in vomiting black blood (melaena), it is 
neither so active nor so copious as when the result of the sepa- 
ration of a slough, a common occurrence during the third week. 
If the latter, no warning whatever may have been given, and 
the haemorrhage itself is accompanied by symptoms of collapse. 
Abdominal distension (meteorism), if excessive, may be taken 
as an indication that the local lesion is severe ; by pressure on 
the diaphragm it may interfere with breathing and with the 
action of the heart, and may even favor perforation. Gurgling 
noises in the abdomen, marked in the right iliac fossa, are very 
common; they are caused by the presence of gas and liquid 
stool in the colon and caecum ; tenderness on pressure is pres- 
ent. Peritonitis results from extension of necrosis, from rup- 
ture of the softened gland, or from perforation of an ulcer. The 
latter is the most serious accident -which can arise in the course 
of the disease. It more frequently occurs in the ileum or colon, 
and it is said that men are more liable to it than women. This 
accident occurs from the fourteenth to the twenty-first day, 



26 SPECIFIC INFECTIOUS DISEASES. 

and is characterized by intense abdominal pain, copious haem- 
orrhage, sudden distension, excessive tenderness and rigidity 
of the abdomen, with pinched face, thread-like pulse, vomiting", 
and other symptoms of collapse. 

The Rash. — There are cases in which the eruption of typhoid 
fever is absent (children) or where, instead of presenting the 
appearance described, it is dark or petechial. In some cases it 
is erythematous, resembling the rash of scarlet fever. Again, 
an irregularly outlined, subcuticular, pale blue eruption may 
appear on the abdomen, chest, thigh (peliomata); this, French 
authorities affirm, occurs where the patient suffers from body 
lice. If there is copious sweating, sudamina and miliary erup- 
tions are found. The more common, pathognomonic eruption 
is felt as an elevation on the skin and disappears in two or 
three days, leaving a brownish stain ; successive crops appear 
during the first two weeks. Eventually, desquamation takes 
place in bran-like scales or in large flakes. 

The glands of the body are frequently involved. Parotitis 
unilateral, often suppurative, is common. The spleen is always 
enlarged, and can easily be found unless the colon is very 
greatly distended ; its size decreases about the twenty-fourth 
day. Infarctions, abscesses and rupture, the latter sponta- 
neous or from slight violence, may take place. The liver at 
times is enlarged ; there may be jaundice, catarrhal or paren- 
chymatous ; rarely hepatic abscess forms. The organs of respi- 
ration may be seriously affected, as by the occurrence of 
bronchitis and lobar pneumonia. Pleuritis, hypostatic con- 
gestion, oedema and haemoptysis may also take place. Char- 
acteristic and important renal complications are not often 
found. Nephritis and pyelitis are occasional complications, 
and even orchitis may appear as a sequel. Muscular changes, 
i. e. fatty degeneration, occur in all continued fevers ; and, as 
an expression of the general cachexia, arthritic inflammations, 
with possible necrosis (tibia), may be noted. 

The Nervous Symptoms have been described. The profound 
prostration is among the most striking phenomena of typhoid 
fever. The tendency to coma vigil is noteworthy, with the im- 
plied absence of violent delirium or mania at any time in the 
course of the disease. In some cases the nervous system first 
and specifically expresses the action of the poison, and then 



TYPHOID FEVER. 27 

well-pronounced symptoms of meningitis, even to convulsions, 
may mark the first stage of the disease. The headache is pecu- 
liarly agonizing, and may continue until conyalesence is well 
established. 

It seems to me that the nervous symptoms are the most re- 
liable indication we possess of the progress of a case, and in the 
absence of fatal haemorrhage, perforation or other startling 
complications, we may treat with considerable indifference 
any untoward symptoms that may arise so long as we are 
capable of relieving to an appreciable extent the pressure 
upon the nervous system. 

As sequels, we occasionally find aphasia (in children), neuritis 
and paralytic affections, the latter usually due to poliomyelitis. 
Confusional insanity, the result of prostration of the nerve 
centers and of impaired nutrition, is sometimes observed. 

Varieties and Relapse. — Attempts to classify types of typhoid 
fever have not proved satisfactory. Complex as the disease is, 
it is natural and proper to express by name the predominance 
of certain symptoms in a case or in an epidemic ; hence we may 
speak of pneumo-typhoid, reno-typhoid, cerebro-spinal-typhoid, 
etc. The term mild (abortive, gastric fever) is used to describe 
the type in which the disease runs a short course and the 
symptoms — such as fever and diarrhoea — at no time become 
threatening. The term "grave" form explains itself. 

In the very young and in the aged typhoid fever presents 
marked characteristics. In the former, the nervous symptoms 
commonly predominate, while the serious intestinal lesions 
rarely occur. Complications and sequelae abound, owing, no 
doubt, to special susceptibility to disturbing influences on the 
part of young children. Among the former, bronchial catarrh, 
and among the latter, aphasia and other nervous troubles, 
scrofulous affections and bone-lesions may be mentioned. The 
mortality is very low. The aged are deficient in powers of re- 
sistance, and thus furnish a high rate of mortality from fatal 
nervous prostration, heart failure and pulmonary complica- 
tions. For similar reasons, i. e., lack of vitality, the fever in 
patients of advanced years is rarely as high and active as in 
younger subjects. 

Relapse proper necessarily presents the pathognomonic 
features of the fever. Liability to it varies in different epi- 



28 SPECIFIC INFECTIOUS DISEASES. 

demies, ranging, according to different observers, from three to 
thirteen per cent. The fever of "recrudescence," and that of 
convalescence, is mild and lacks the pathognomonic symptoms. 

Morbid Anatomy. — The symptoms of the disease suggest the 
anatomical changes which produce them. The characteristic 
lesion is intestinal, involving the glandular tissues, especially 
and primarily those of the jejunum and ileum, also of the large 
intestine. The fixation of the bacilli in the deeper glandular 
structure of those parts is soon followed by a well-defined 
hyperplasia with infiltration and resulting pressure on the 
blood vessels, giving the parts a pale, anaemic appearance ; this 
condition is most marked from the third to the tenth day. 
Either resolution takes place or the morbid action continues, 
going through necrosis and sloughing (superficial or deep, 
especially severe near the ileocecal valve, and occasionally in- 
volving large portions of the gut), with subsequent ulceration. 
The ulcers appear singly or in patches, with smooth, clean 
base, and soft (hence, easily bleeding), swollen, at times under- 
mined, jagged edges: they are oval, rounded, irregular. It is 
at this time that perforation and severe haemorrhage occurs 
from the extension of the necrosis through all the coats of the 
diseased intestine. Healing of the ulcers takes place by granu- 
lation, leaving a slightly depressed, often pigmented, surface. 
The mesenteric glands, the spleen, the liver, and the kidneys 
show evidence of deep tissue degeneration of a granular, fatty 
or waxy character, with liability to necrotic processes and, 
especially in the spleen, a tendency to rupture spontaneously 
or from slight injury, such as from rough touch. Myocarditis, 
with granular, fatty changes — more rarely endocarditis — has 
also been found after death. The arteries and veins may be 
similarly involved, and thrombi, especially femoral, have been 
noted. 

Diagnosis. — The diagnosis of typhoid fever in the early stage 
should be made with caution. While the characteristics of the 
disease, as described in the lecture room and in a text-book, 
seem so pronounced as to forestall the possibility of mistake, 
the fact yet remains that disease, as found in the sick-room, 
does not frequently present the clear-cut picture with which the 
young practitioner is familiar. Yet, the gradual onset of the 
disease, the profound and early nervous prostration, the char- 



TYPHOID FEVER. 29 

acteristic rash and the temperature record, and later the path- 
ognomonic intestinal symptoms and complications, are suffi- 
cient to establish the diagnosis. 

Bronchitis and, more frequently, pneumonia, occurring as a 
complication of typhoid fever, may so cover up the case that 
the chief difficulty may be overlooked. Such a mistake might 
easily be made if it should so happen that the pathognomonic 
symptoms of typhoid fever are not well-pronounced. 

Cerebrospinal meningitis frequently resembles typhoid fever. 
A differential diagnosis in the earlier stage of the disease must 
largely rest upon a careful consideration of the surroundings. 
Keeping in view the fact that cerebro-spinal meningitis is a 
disease of rare occurrence, and the possibility of finding symp- 
toms of meningeal irritation in connection with typhoid fever 
in its early stage, the prevalence of typhoid fever in the neigh- 
borhood, or a knowledge that local conditions and the season 
of the year are such as to favor the appearance of typhoid 
fever, would be important considerations. The appearance, 
later, of pathognomonic symptoms will establish the diag- 
nosis. 

Remittent fever and typhoid fever may be mistaken one for 
the other. This would most commonly occur in malarial dis- 
tricts, especially in cases of remittent fever characterized by 
unusual depression of the nervous system. But the face in 
remittent fever lacks the continuously stupid, drawn, haggard 
look of typhoid fever ; it is at all times more animated, and 
during the pyrexia the redness is more vivid, with greater in- 
jection of the eyes. The early semi-jaundiced sallowness of the 
skin of remittent fever is wanting in typhoid, and while in the 
former the tongue may become dry, brown, and cracked, the 
tremulousness and unsteadiness with which it is protruded in 
typhoid fever is lacking in all save very exceptional cases : the 
pulse, also, is firmer and more resisting to pressure, unless in 
the late stage of a very protracted and serious case. While the 
nervous system may be profoundly affected, the depression is 
not so severe as in typhoid. 

Acute miliary tuberculosis presents a totality of symptoms 
strikingly similar to typhoid fever when the respiratory organs 
are involved. Both have similar manifestations of bronchial 
and pulmonary involvement, a period of general inertia often 



30 SPECIFIC INFECTIOUS DISEASES. 

preceding the fever, and intestinal disturbances, even to bloody 
stools and splenic enlargement. The fever, however, of acute 
miliary tuberculosis is much more irregular and the remission 
may be from two to three degrees ; breathing is more rapid 
and the cyanotic tendency more pronounced. The enlargement 
of the spleen does not occur so early, neither is it so marked. 
The typhoid eruption is wanting, although skin symptoms, 
usually numerous but isolated red spots, ma}- be present in 
tuberculosis. 

Prognosis. — The prognosis should be very guarded. It is 
difficult in the beginning to determine the probable severity of 
the case, neither can dangerous complications be anticipated 
and weighed. The general tone of the system and the patient's 
powers of resistance are important considerations. Struempell 
states that under modern treatment the average mortality is 
about ten per cent. 

Treatment. — Prophylaxis. — Thorough drainage and supply 
of pure water for drinking and cooking constitute the most 
effective protection of a community against typhoid fever, A 
case of the disease having occurred, strenuous efforts must be 
made to find its origin, and all sources of suspected water must 
at once be cut off, and all water used for drinking or cooking, 
as well as all the milk used, must be thoroughly boiled ; thus 
the bacilli are killed. Filtering alone is not sufficient. 

In the sick room absolute cleanliness must be observed. Bed 
and bedding must be handled as little as possible, and the fol- 
lowing rules, suggested by Fitz, should be observed: "Mat- 
tresses and pillows, when liable to become soiled, are to be 
protected by close-fitting rubber covers. Bed and body linen 
are to be changed daily. Bed-spread, blankets, rubber sheets 
and rubber covers are to be changed at once when soiled. 
Avoid shaking any of the articles. All changed linen, bath 
towels, rubber sheets and covers are to be immediately 
wrapped in a sheet, soaked in carbolic acid (1:40). Remove 
them to the rinse-house as soon as possible, and soak one hour 
in carbolic acid (1:4-0). Then boil the linen for a half-hour, and 
wash with soft soap. The rubber sheets and covers are to be 
rinsed in cold water, dried, and aired for eight hours. The bed- 
spreads and blankets are to be aired eight hours daily. Feed- 
ing utensils, immediately after using, are to be thoroughly 



TYPHOID FEVER. 31 

cleansed in boiling water. Dejections are to be received in a 
bed-pan containing half a pint of carbolic acid (1:20), in divided 
portions. The nates are to be cleansed with paper, and after- 
ward with a compress cloth wet with carbolic acid (1:40). 
Add two quarts of carbolic acid (1:20), in divided portions, to 
the contents of the bed-pan ; mix thoroughly by shaking, and 
throw the liquid into the hopper. The bed-pan and hopper are 
to be cleansed with carbolic acid (1:20), and wiped dry. The 
cloth used for the above purpose is to be at once burned. The 
corpse is to be covered with a sheet wet with carbolic acid 
(1:40). After the discharge of the patient from the hospital 
the mattresses are to be aired every day for a week. The bed- 
stead is to be washed with corrosive sublimate (1:1000)." 

The American Public Health Association recommends the 
following standard solutions : 

Standard Solution No. 1. — Dissolve chloride of lime, of the 
best quality, containing at least 25 per cent of available 
chlorine, in pure water, in the proportion of four ounces to the 
gallon. Use one quart of this solution for the disinfection of 
each discharge. Mix well and leave in vessel at least one hour 
before throwing into privy-vault or water-closet. 

Standard Solution No. 2. — Dissolve corrosive sublimate and 
permanganate of potash in pure water in the proportion of 
two drachms of each salt to the gallon. Use for same pur- 
poses, but must be left for at least four hours in contact with 
the material to be disinfected. It is odorless, very poisonous, 
and will injure le#id pipes if passed through them in consider- 
able quantities. Must not be kept in a metal receiver. The 
surface of the body of a sick person, or of his attendants when 
soiled with infectious discharges, should at once be cleansed 
with a solution of chlorinated soda, diluted with three parts of 
water, or with a two per cent solution of carbolic acid. As to 
the clothing, it must be kept for a half-hour in boiling water, 
and then laundried ; this must be done at once upon removal 
from the person or bed of the sick. 

Standard Solution No. 3. — Dissolve four ounces of corrosive 
sublimate and one pound of sulphate of copper to a gallon of 
water. Two fluid ounces of this solution to the gallon of 
water will disinfect clothing if thoroughly soaked with it for at 
least two hours, after which they may be wrung out and sent 



32 SPECIFIC INFECTIOUS DISEASES. 

to the wash. Soiled mattresses, pillows, feather beds, etc., can- 
not be effectually disinfected by sulphur fumigations, because 
the gas does not sufficiently penetrate them. Destruction by 
fire is here advised. 

Free ventilation and cleanliness must be practiced. Neutral- 
izing bad odors is not disinfection. Plastered walls and ceil- 
ings must be brushed over with one of these solutions, and 
then white- washed. The same treatment must be applied to 
the wood-work, taking especial pains to remove every particle 
of dust; this must be followed by thorough scrubbing with soap 
and hot water, and a prolonged exposure of the room to fresh 
open air by opening both doors and windows. Finally, sul- 
phur fumigations (at least three pounds of sulphur to each 
1,000 feet of air space), with usual precautions as to absolute 
closure of every aperture, will complete the process of disinfec- 
tion. 

General Management. — The patient must be put to bed at 
once, and must remain there until well. Do not attempt by 
internal medication to destroy the bacillus ; the attempt is use- 
less, and the patient will suffer from the administration of 
powerful drugs. Keep the room well ventilated, sunny, and at 
a temperature of 68° at the head of the bed. An extra lounge, 
for the use of the sick one, should be in the room, and the bed 
should be supplied with air cushions or water-bed. The pa- 
tient must be kept scrupulously clean ; his linen is to be changed 
as often as necessar}- to secure this end, but it is not wise to 
insist on daily change if the patient is fretted or tired by it. 
See that he is not allowed to remain too long in one position ; 
have the nurse gently turn him from side to back, and direct 
that Florida water or Eau-de-Cologne be occasionally used to 
refresh him. Keep the mouth clean by frequent bathing with a 
soft cloth dipped in cold water, to which a pinch of borax may 
be added ; thus excessive soreness of the tongue and lips may 
be largely prevented, and the danger of stomatitis, and even 
parotitis, materially lessened. Vaseline or glycerine should 
occasionally be applied to the lips. 

The prevention of bed-sores is of great importance. To this 
end frequent bathing, especially of the sacrum and heels, in 
brand}-, alcohol or spirits of camphor must not be neglected. 
If a bed-sore appears, it must receive the closest attention, 



TYPHOID FEVER. 33 

being kept clean and bathed in a weak solution of carbolic 
acid. German practitioners use an ointment of balsam of 
Peru, one part with thirty parts of glycerite of starch. Dust- 
ing with iodoform or some similar dry preparation is to be prac- 
ticed if the sores are large, and the knife may have to be called 
into requisition if extensive necrosis develops. 

The patient should not only be allowed to drink freely of 
pure, cool water, but the attendant must be instructed to ad- 
minister cool water at short intervals. Water containing car- 
bon dioxide is not to be allowed, since it increases gaseous dis- 
tension of the intestine. 

The diet, until convalescence is well established, should be 
liquid, and cool milk meets the requirements better than any 
other food. To an adult a quart of good, rich milk may be 
given daily, diluted with water; if more, it must be skimmed. 
Occasionally patients readily take quite cold milk when they 
rebel against it warm. I have never seen harm follow the use 
of cold milk -when a craving for it existed ; in fact, iced milk 
often agrees nicely and may relieve persistent vomiting. If, as 
is often the case, the patient tires of milk as an exclusive diet, 
or if he prefers sour milk, buttermilk, or koumyss, these may 
be used, at first with caution. The presence of curd or of 
copious oil globules in the stool — and pains must be taken 
to "watch for these — denotes indigestion and counter-indicates 
the continued free use of milk. Chocolate, broths, blanc-mange, 
the white of egg beaten in water, baked apple, and later 
" Zwieback " soaked in milk or "water, may be allowed. Thinly 
shaved raw beef may be relished for a change and answers 
well if dilute hydrochloric acid be used to aid in its digestion. 
Sometimes beer or a light wine (port, Hungarian) is accepta- 
ble. 

That there is danger from the use of solid food before the in- 
testinal lesion is well advanced toward recovery is generally 
admitted. Even after convalescence has been established, the 
patient, whose now craving appetite constantly tempts to vio- 
lation of strict dietetic rules, should be watched so as to insure 
safe and complete recovery. 

The cool bath, as now practiced, is a modification of and im- 
provement upon the method of Brand, of Stettin, Germany, 
and has proved very useful in the treatment of typhoid fever. 
3 



34 SPECIFIC INFECTIOUS DISEASES. 

The claims made in its behalf are in substance these : It dimin- 
ishes the fever. By its tonic action it sustains the nervous sys- 
tem ; under its use the "typhoid" state is modified, the intel- 
lect brightens, and experience shows that it lessens the ten- 
dency to pulmonary complications. The skin is kept in good 
condition, and bed-sores occur less often. It stimulates the ac- 
tion of the kidneys, thus favoring the excretion of typhotoxines. 
Its employment has lessened the death rate. 

The bath is indicated whenever the temperature in the rectum 
reaches 103°, or more. If a bath-room is convenient to the sick 
room, it will prove very advantageous ; if not, a bath-tub of 
full size must be placed near the bed. The patient is carefully 
lowered by sheets held at the four corners, immersed up to the 
neck, and supported by the attendant in order to prevent ex- 
haustion. The temperature of the water should be from 85° to 
90°, or even warmer if the patient is sensitive to cold ; it may 
be gradually lowered by adding at brief intervals lumps of ice. 
The bath should be continued for ten or twelve minutes, gentle 
friction of the skin being maintained to prevent the patient 
feeling chilly. If the patient seems uneasy or cold, he is to be 
removed at once ; otherwise, at the lapse of ten minutes he is 
lifted into bed, quickly wrapped in sheets and wiped dry, when 
the wet sheets are taken away, the patient covered, and given 
a bit of wine, brandy or food. If the effect of the bath is good, 
an examination of the temperature in the rectum (in typhoid 
fever the temperature should always be taken in the rectum) 
will within a half-hour show a lowering of from 2° to 3°. The 
frequency of the bath must be governed by the strength of the 
patient, the height of the fever, and by its effects on the patient. 
It may be given every three or four hours, and generally it is 
safe to maintain this both day and night until the hyperpyrexia 
has yielded. The physician must closely watch the effects, and 
discontinue the treatment the moment it proves unsatisfac- 
tory ; neither must he overlook the fact that the irregular, too 
infrequent or unsystematic use of the bath defeats the object 
for which it is given. If pulmonary complications exist, the 
temperature of the bath must be higher ; this applies also to 
cases where meningeal irritation is present ; in the latter case 
cold water is to be poured on the head and back, protecting 
the ears by stopping with cotton or wool. Counter-indica- 



TYPHOID FEVER. 35 

tions to the use of the bath are: Too much fretting and sensi- 
tiveness on the part of the patient ; excessive weakness ; ap- 
pearance of rheumatoid pains after the bath; peritonitis, intes- 
tinal haemorrhage, otitis, laryngitis, nephritis. 

Severe intestinal haemorrhage may be relieved by the use of 
ice-bags on the abdomen; opium, in appreciable doses, by 
checking peristalsis and thus favoring the formation of a clot, 
may be advisable. In case of collapse stimulants are impera- 
tively indicated. Of particular value are: Black coffee with 
cognac; camphor, grs. 2 to 5 ; musk, grs. Y2 to 1. Alcohol in 
any form. Nitro-glycerine. Cold water to the chest, to start 
breathing ; artificial respiration. 

Save in a crisis, or to meet special emergencies, the use of 
stimulants, in my own experience, has proved injurious rather 
than beneficial. Many practitioners endeavor to sustain 
vitality by ordering large amounts of alcohol, often from 8 to 
12 ounces of whisky per day. Fully realizing the beneficent 
effects of stimulants in asthenic states, I expect better results 
from an occasional egg-nog containing not more than a tea- 
spoonful of whisky than from larger amounts. My own 
favorite method is to add a teaspoonful of the best whisky or 
of absolutely pure alcohol to a glassful of cold water, at short 
intervals giving the patient a spoonful of this solution. This 
rule, of course, is not intended to apply to emergencies, when 
the doses must be appreciable. 

Therapeutics. — So far, no remedy has been discovered which, 
infection having taken place, can destroy the bacillus and cut 
short the constitutional manifestation of its specific action. 
The disease is self-limited, and all that medicine can do is to 
sustain the vitality of the sick, to reduce to a minimum the 
mischief accomplished, and to meet the symptoms of the case 
as they arise. But this simple proposition embraces a great 
deal. 

Arsenicum album. The provings of arsenic show a re- 
markable similarity between the pathogenetic symptoms of 
the drug and the symptoms of this fever, covering not only 
many of the most important gastric, intestinal and urinary 
symptoms of the disease in various degrees of violence, but giv- 
ing a graphic picture of the so-called typhoid state, with its 
utter prostration of the vital forces and other characteristic 



36 SPECIFIC INFECTIOUS DISEASES. 

manifestations in the nervous S3^stem, even in its minute de- 
tails, including the slow, tedious convalescence itself and many 
of its most serious accompaniments. 

The individuality of the remedy is such that it rarely proves 
of much value in trifling disorders ; the very seriousness of a 
disease suggests arsenic. Its chief usefulness lies in cases which 
from the beginning betray intensity of morbid action, as shown 
by great exhaustion from very slight exertion and an early 
drifting into the typhoid state. The more pronounced these 
symptoms, the more useful arsenicum is likely to be. The gen- 
eral condition is one of great prostration and weakness, the 
slightest exertion being followed by faintness ; this is often as- 
sociated with a restlessness which makes the patient keep 
hands and feet moving incessantly and automatically. He lies 
stupid, perceives nothing, asks for nothing, complains of noth- 
ing. The tongue and lips are dry; the former is dark red, 
blackish, cracked, stiff, rendering speech difficult ; the latter, 
and the teeth, are covered with sordes. The mouth is ulcer- 
ated. The pulse is small, frequent, often irregular ; the flesh feels 
hot and dry, sometimes cold, with clammy perspiration ; the 
cheeks may be hot and red. Delirium of a low character ; coma 
rare ; stools frequent, watery, dark, blood\ r , putrid, worse after 
eating or drinking. Urine scanty, high-colored, of cadaverous 
odor; retained. Gastric irritability. Great emaciation. Ten- 
dency to haemorrhage from the orifices of the body. Petechia?. 

Baptisia has made an excellent record in the lighter forms 
of this disease. It is particularly useful in the so-called gastric 
fever, and in light doses of the mother tincture has aborted 
many cases in which no question as to the correctness of the 
diagnosis could be entertained. In the early stage of the fever 
the weariness is great ; there is severe, dull, stupid headache ; 
great aching and soreness of the 'body; pains in the bowels; 
uneasiness in the liver; slight tendency to vomit; yellowish 
coated tongue ; fetor of the breath ; mushy diarrhoea. 

Later, and in graver cases, the characteristic "physical de- 
pravity " of the remedy is shown more plainly ; the face is of a 
dark-red, livid color, with besotted expression ; tongue dry, red 
or of a brown color, with reddish edges ; the tired, bruised, sick 
feeling all over is very pronounced ; sordes on the lips and 
teeth; the severe, dull headache continues; it is difficult to 



TYPHOID FEVER. 37 

rouse the patient, and there is ajow, muttering delirium in 
which the patient fancies his legs are cut off, that a second self 
is in bed with him, lying by his side, or that he is kept busy 
putting himself together. 

Rhus toxicodendron stands between Baptisia and Ar- 
senic. It is well suited to persons of strong, vigorous con- 
stitution, and in the typical Rhus case there is less "lingering " 
than under Arsenic. A feeling of "great illness," a sort of ner- 
vous apprehension, runs ahead of the disease, and when the 
attack begins the patient is overcome with the consciousness 
that he had a "warning;" hence, he gives up easily to the sense 
of -weakness and favors himself, while in reality he is not as 
weak as he fancies ; the Arsenic case, on the other hand, is not 
conscious of the extreme exhaustion until after an exertion 
has demonstrated it. 

The disease once fully declared, we find genuine and great 
weakness, with, at first, an over-excited state of the nervous 
system, with sensitiveness to light and noise, followed by cor- 
responding depression and atony. A peculiar feature of the 
Rhus # case is the evident consciousness on the part of the 
patient of the depression of the sensorium and of the reasoning 
powers, with seeming anxiety to cover this ; eventually, how- 
ever, the patient's thoughts become mixed and he surrenders 
himself to the characteristic typhoid state, talking and mumb- 
ling to himself. Other indications are : Predominance of heat, 
with redness of the face and injection of the eyes. Early and 
frequent bleeding from uterus and nose, followed by temporary 
relief of general symptoms. Greenish-brown diarrhoea, not 
nearly so offensive as that of Arsenic and Baptisia. Urine 
looks like whey. Rheumatoid pains. Pulmonary congestion, 
with sticking pains in sides, short breathing and dry, hacking 
cough. 

Lachesis The patient is restless and loquacious ; he jumps 
from one subject to another in an incoherent manner; there 
is stupor, dropping of the lower jaw, dry, red or blackish 
tongue, which is red at the tip and bleeding, and trembles on 
being protruded; the stools are horribly offensive, the abdomen 
sensitive to touch, and all symptoms are more intense after 
sleep. The fever is highest in the afternoon. 

Ranking next in importance are the mineral acids, more espe- 



38 SPECIFIC INFECTIOUS DISEASES. 

dally Phosphoric and Hydrochloric acid. They should be 
used in aqueous solution, just strong enough to give a slightly 
acidulated taste. 

Acid phosphoricum. Especially useful in elderly people, 
with low powers of resistance, hence slow to recover. This 
lack of power to "react" furnishes the key to the symptoms 
which indicate its use. The depression shows itself early 
in the course of the disease, and is general. Fever and temper- 
oture are low, the latter even subnormal. As under Baptisia, 
the delirium is low: the patient is roused with difficulty, an- 
swers questions slowly, then sinks back into apathy ; but the 
"foulness" of Baptisia is absent. Dullness of special senses, 
especially of hearing. Tongue pale, moist ; skin loose, com- 
paratively plump, clammy. Stools watery. Characteristic dis- 
organization of blood, with ecchymosis and bleeding; the 
latter affords no relief. Threatening pulmonary complications, 
indicated by various crepitations and rhonchi, but little cough. 

Acia. hydrochloricum. Muriatic acid lacks the great 
prostration of Phosphoric acid ; the symptoms are more ag- 
gressive ; the typhoid state proper more pronounced. Trinks 
highly recommends it in the febris nervosa versatilis, with 
continuous, moderately active, but not violent, delirium, 
great acuteness of the special senses, general dryness of the 
mucous membrane, with slight congestion, keeping up the de- 
lirium and preventing rest. Pulse soft, rapid, from 110 to 130. 
Later, intermitting pulse, often every third beat; febris stupida; 
tongue so trembling and weak that the patient cannot pro- 
trude it ; sliding down in bed ; involuntary stools and urina- 
tion. 

When the intestinal symptoms are especially severe, a class 
of remedies may be called for of which Mercury and Nitric 
acid are the most important. 

Mercurius solubilis (or Mercurius vivus), used not lower 
than the third decimal trituration, is very valuable if after the 
first few days of illness hepatic symptoms show themselves, 
with great sensitiveness to slight pressure in the gastric, he- 
patic and inguinal regions ; icteric hue of the skin. The tongue 
is flabb}-, moist ; the stools are frequent, copious, greenish and 
slimy, with admixture of blood. 

Mercurius corrosivus is indicated by danger or evidence 



TYPHOID FEVER. 39 

of peritonitis, with tenesmus and bloody, slimy stools; "dysen- 
teric " symptoms. 

Acid. Nitricum covers many important intestinal symp- 
toms. Its action upon the mucous membrane is decided; 
it produces ulcers in the mouth and in the intestinal tract. Its 
concomitant symptoms are those of intestinal ulceration. 
There is great distension of the abdomen, with 'intense tender- 
ness. The stools are green, slimy, acrid, fetid, and often accom- 
panied with tenesmus. The appearance of the patient is pale, 
haggard ; he is anxious, irritable, and, like the Arsenic case, 
feels sure that he cannot get well. In case of intestinal haemor- 
rhage, especially with rapidly progressing emaciation and 
threatening pulmonary complications (rattling cough, brown- 
ish, bloody, purulent expectoration), it is a valuable remedy. 

Other remedies are indicated by special conditions. Of these, 
Phosphorus deserves especial mention because of its close rela- 
tion to all states of adynamia and its action upon the respira- 
tory organs. These alone suggest its use in cases with pul- 
monary complications. Its clinical record has been very satis- 
factory. Bryonia is of use chiefly in light cases, with such 
gastric and hepatic complications as belong to the remedy ; its 
characteristic "touchiness" and delirium (about the affairs, 
especially business, of the previous day) are also to be borne in 
mind. Gelsemium is of no use in the true typhoid state, but 
close relationship to malarial conditions suggests when it may 
prove of service. 

In exceptional cases the brain-symptoms overshadow every- 
thing else. If so, Zincum, Belladonna, Hyoscyamus, Stra- 
monium, Agaricus and Opium must be carefully studied. Zin- 
cum and Opium are of unquestioned value in widely differing 
conditions ; the former in true inflammatory conditions of the 
brain and its covering, the latter in profound and character- 
istic coma. 

Hale recommends Salicin for symptoms usually considered 
suggestive of quinine. He also speaks earnestly of the useful- 
ness of Eucalyptol. "When taken into the alimentary canal, it 
mixes with and disinfects its contents, destroys or prevents the 
multiplication of bacilli, and neutralizes their toxic products." 
He recommends the tincture of Eucalyptus globulus in doses 
of five to ten drops every three or four hours. 



40 SPECIFIC INFECTIOUS DISEASES. 

The action of the heart may be embarrassed in the course of 
the disease, and in case of the in\^olvement of the heart muscle, 
Arsenicum, Phosphorus and other remedies will come into 
play. Cardiac tonics, like Digitalis, Strophanthus or Con- 
vallaria, mav be called for. 



TYPHUS FEVER. 

Synonyms: Exanthematic typhus. — Spotted fever. — Camp 

fever. — Hospital fever. — Ship fever— Jail fever. — Famine' 

fever. — Putrid continued fever. — Irish ague. 

General Description and Causation: Typhus fever is an acute 
infectious disease, epidemic in character, intimately associated 
with want and filth. As one of the "plagues" of the dark 
ages, it frequently devastated entire and populous districts. 
With a clearer understanding of the rules of sanitation and 
with better living, it has largely disappeared. It is still met in 
Ireland, Great Britain, Russia, Poland, Mexico, and other coun- 
tries where ignorance, poverty, overcrowding and want pre- 
vail. Only a few epidemics of t^^phus fever have occurred in 
this country ; the first epidemic in the United States was that 
of 1812 in New England ; the last, that of 1893 in New York. 
These were due to immigration. It is a question whether, or 
not, spontaneous cases ever occur. 

The disease is highly contagious. Its specific poison is not 
only retained for a long time in the bedding and clothing of the 
sick, and is thus communicated to others, but it is readily 
transmitted to all who are forced into association with the 
infected person. Whether this is accomplished by the excre- 
tions and secretions, by the air exhaled, or by the scales which 
the epidermis throws off, is an open question; but it is well 
understood that exposure for any length of time involves great 
danger of infection, especially on part of the nurse, and that 
this danger is materially lessened if there can be had an 
abundance of fresh air in the sick-room. Thus Struempell 
states that "in the well-ventilated pavilions of the Leipzig 
hospital there have rarely been cases of transfer of the disease 
to physicians, nurses, or other patients." Since one attack of 



TYPHUS FEVER. 41 

the disease practically gives immunity from a second infec- 
tion, the attending nurse, when possible, should be one who at 
some previous time has had the disease. 

Typhus fever may appear at any season of the year. It 
affects all ages, with, probably, a preference for persons of from 
twenty to forty years old. As yet, no specific micro-organism 
has been discovered which meets the conditions of Koch's law. 

Morbid Anatomy. — No changes, post mortem, have been 
noted. The dark, fluid condition of the blood, and the granu- 
lar degeneration of muscular tissue repeatedly observed, pre- 
sent nothing peculiar to this disease alone. Enlargement of 
the spleen and catarrh of the bronchia are among the more 
important minor changes described. 

Symptomatology. — In the larger number of cases the onset of 
the fever is sudden. There is a severe chill or rigor, followed 
by high fever, with full and rapid pulse, great prostration, 
headache, and pains in the back and legs. The chill may recur 
within a few days. The fever is high, at times with a tem- 
perature of 104° or 105° as early as the first evening, usually 
reaching its maximum within two or three days. Anorexia, 
with white, dry tongue, headache, vertigo, ringing in the ears, 
flushed face with dull, stupid expression, blood-shot eyes, vom- 
iting, and symptoms of bronchial catarrh develop rapidly. 

The eruption usually appears from the third to the fifth day, 
exceptionally as late as the seventh day ; in rare cases it is very 
light and may even be absent. It first shows on the trunk, 
then on the extremities ; the face is rarely involved ; it reaches 
its fullest development within two or three days. ''There are 
two elements in the eruption, a subcuticular mottling, a fine, 
irregular, dusky red mottling, as if below the surface of the 
skin some little distance, and seen through a semi-opaque 
medium (Buchanan) and distinct papular rose spots which 
change to petechias" (Osier). The haemorrhagic, petechial 
character of the eruption constitutes one of the most striking 
features of the disease. Some observers maintain that a char- 
acteristic odor is noticed at this time. "Pari passu with the 
appearance of this eruption, there is exhaled by the patient a 
special characteristic odor — an odor which my great teacher 
Jimenez was in the habit of comparing to that given off by the 
domestic mouse. That observer considered this peculiar odor 



42 SPECIFIC INFECTIOUS DISEASES. 

of paramount importance, as he was never able to perceive it 
in those fevers which accidentally assumed the typhoid form" 
(Manuel Dominguez). 

The temperature is not lessened with the appearance of the 
eruption, and the patient during the second week drifts into a 
condition which resembles typhoid fever in its great prostra- 
tion and prominence of nervous symptoms. Delirium is con- 
stant ; the pulse increases in rapidity and weakness ; the face 
grows dusky, stupid and expressionless ; he lies on the back 
unconscious, with eyes wide open, breathing rapidly and super- 
ficially ; the tongue is dry, brown, cracked ; the teeth and lips 
are covered with sordes ; there is subsultus tendinum, picking 
at the bedclothes, and retention of urine. Death may occur 
from exhaustion. 

In case of favorable termination, recovery takes place by 
crisis at the end of the second week. Commonly, after a deep 
sleep, the patient awakes refreshed, the temperature falls, the 
threatening symptoms disappear with surprising readiness, 
and, though gaining strength slowly, he makes an uneventful 
recovery, rarely interrupted by a relapse. 

In some cases the onset of the disease is not sudden, as de- 
scribed, but the patient, before the appearance of the chill and 
fever ; for a period of from seven to ten, or even twelve, days, 
suffers from lassitude, indisposition, weariness, and anorexia, 
with white coating of the tongue, dull headache, gastric dis- 
comfort, and heavy aching in the extremities. In cases of un- 
usual severity the attack is frequently ushered in with excep- 
tionally high fever, accompanied with delirium and other evi- 
dence of marked cerebral disturbance. 

The fever, always high, is at its maximum about the fifth 
day, when the thermometer may register from 105° to 107°. 
At no time are morning remissions as marked as in typhoid 
fever; the maximum temperature once passed, remissions become 
somewhat more pronounced. After the crisis the temperature 
rapidly falls and may be below normal within twelve or twenty- 
four hours. A temperature of 108°, or more, indicates a fatal 
termination. Pulmonary symptoms in all severe cases are 
those of hypostatic congestion. The urine shows absence or 
decrease of chlorides, increase of urea and uric acid, and some- 
times albumin. 



TYPHUS FEVER. 43 

Occasionally cases occur in which the symptoms are very 
light, with little fever and only trifling disturbance in the 
nervous system, recovery taking place in from ten to twelve 
days. On the other hand, cases are noted where the onset of 
the disease is violent, all the symptoms intense, and death takes 
place in a few days. 

Complications and Sequelae. — The complications most likely 
to arise are broncho-pneumonia, parotitis, jaundice and bed- 
sores ; broncho-pneumonia is both frequent and serious. Osier 
mentions a tendency to gangrenous processes which has charac- 
terized some epidemics, and which involves the toes, hands, 
nose, and lungs ; of the sequels, anaemia and post-febrile 
neuritis, resulting in paralysis, are the most important. 

Prognosis. — In the young the rate of mortality is low; 
children rarely die of the disease ; after middle age the rate is 
correspondingly high, even reaching fifty per cent. The aver- 
age mortality is from twelve to twenty per cent. Of the 185 
cases treated at the Riverside Hospital, on North Brother 
Island, New York, early in 1893, twenty-eight died. Death 
commonly results from toxaemia or pulmonary involvement. 

Dominguez, a Mexican authority, speaking of typhus in his 
own country, gives a higher rate of mortality, stating that in 
the endemic form it varies from twenty to twenty-five per cent., 
including persons of all ages and sexes, and from fifty to sixty 
per cent, when the disorder takes an epidemic course. He adds 
that in Mexico the mortality is always greater among the 
higher classes of society. He also states that "concentrated 
pulse, the frequency of which gives to the beating artery under 
the finger the character of a soft, loose cord in continuous 
vibration " is a very bad symptom. 

Diagnosis. — Typhus and typhoid fever may present sufficient 
similarity, symptomatically, to render a differential diagnosis 
a matter of no small difficulty, especially so in cases which 
appear to be sporadic. Taking into consideration the existence 
or non-existence in the neighborhood of cases of either disease, 
and the season of the year, the diagnosis of typhus fever must 
rest upon the more abrupt onset of the disease; the greater 
intensity of nervous symptoms in the early stage ; the severity 
of the pains in the extremities and loins; the continuously 
higher temperature ; the absence of marked and regular morn- 



4-4 SPECIFIC INFECTIOUS DISEASES. 

ing remissions in the fever; the absence of abdominal symp- 
toms which are characteristic of enteric fever ; earlier appear- 
ance of the rash, which is more extensive and of a pronounced 
hemorrhagic character ; the shorter course of the disease, and 
recovery by crisis. Whittaker sa3 r s "there is bronchitis in both 
diseases, but there is also eoryza in typhus fever, with irritation 
in the nose, sneezing, which almost never occurs in typhoid." — 
Measles and typhus, in children, have points in common. In 
measles, however, the catarrhal symptoms precede by two or 
three days the onset of the disease ; in typhus they are con- 
comitants. The eruption of measles appears in patches and 
early involves the face ; that of typhus is much more generally 
and evenly distributed, and hardly ever involves the face. The 
character of the eruption almost alwa3 r s admits of differentia- 
tion, that of measles remaining macular, while that of typhus 
is petechial ; the former disappears by desquamation in bran- 
like scales, the latter by absorption. — Small-pox may be mis- 
taken for typhus, especially when it appears in a malignant 
form. One of the most valuable diagnostic points is the relief, 
especially lowering of the temperature, which in small-pox 
accompanies the appearance of the eruption. The eruption 
itself in variola first appears on the scalp, forehead and face ; 
in typhus, on the trunk, extremities, rarely on the face ; umbili- 
cated vesicles, common in small-pox, are not seen in typhus. 
The haemorrhagic tendency and bleeding from the mucous 
membranes is also more pronounced in small-pox. 

Treatment. — The general directions for treatment of typhoid 
fever are applicable here. Isolation of the patient is of the 
greatest importance. Especial attention must be paid to 
the condition of the sickroom. Not only must there be an 
abundant supply of fresh air, day and night, but every 
unnecessary article of furniture must be removed from the 
room. Carpets, rugs, and clothing not immediately needed 
must be taken out at once and carefully disinfected. Absolute 
cleanliness and disinfection must be practiced unceasingly, for 
upon these depends not only the welfare of the patient, but the 
comparative safety of all who are obliged in any way to asso- 
ciate with him. The attendants must also look after their 
physical comfort, avoiding too much fatigue, and eating abun- 
dantly of nourishing and easily digested food. 



RELAPSING FEVER. 45 

The bath is efficient in the treatment of hyperpyrexia; the 
precautions enumerated in the preceding chapter must be ob- 
served. Everything must be done to economize the strength 
of the patient, and it is a matter of great importance not to 
permit unnecessary exertion on his part. The diet should be 
liquid, easily digested, but generous within the limits of safety. 
The bowels are to be kept open by the use of appropriate ene- 
mata (water and milk; strong -warm soap-suds), and in case 
there is tendency to constipation, thin gruels may be fed freely. 
Slightly acidulated drinks may be allowed. Stimulants, judi- 
ciously used, are not objectionable. 

Therapeutics. — Consult the remedies given under "Typhoid 
Fever." Additionally 

Aconite will be useful in cases "where the onset of the dis- 
ease is very abrupt and symptoms of congestion are present, 
with great tension and excitement, especially in people of a 
nervous, sanguine temperament. The pulse is quick, hard, 
and sharp ; the patient is "on the move ' ' constantly, throwing 
himself rapidly and energetically from side to side ; face and 
eyes flushed ; great thirst ; fullness in the forehead, with feeling 
as if the brain would start out of the eyes. Hard chill, or well 
defined rigor, followed by high fever, with pungent, hot skin. 

Veratrum viride in cases which from the beginning manifest 
great intensity of morbid action. The pulse is hard, quick, 
full, and bounding, and there is much irritation of the cerebro- 
spinal nervous system, with restlessness, boring the head into 
the pillow, jerking, twitching, tendency to convulsive action ; 
he lies on the back, the thighs flexed on the pelvis ; picking of 
bed-clothes, etc., subsultus tendinum. Tongue coated white; 
red streak in the middle. 

Other remedies to be studied are : Arnica, Secale cornutum, 
Apium virus ; possibly in light cases, Gelsemium. 



RELAPSING FEVER. 

Synonyms: Relapsing- Typhus. — Recurring- Fever. 

General Description and Causation: An acute infectious dis- 
ease due to, or characterized by, the presence in the blood of 



46 SPECIFIC INFECTIOUS DISEASES. 

the spirochetes or spirillum of Obermeier, demonstrated in 
1873. These micro-organisms under the microscope appear 
like dainty, narrow threads, from three to six times as long as 
the diameter of the red blood-corpuscle; they possess spiral 
and undulatory, snake-like motion, and may be seen singly or 
in knots of four to twenty. They are found onh^ in the blood, 
and their increase in, and disappearance from, the blood goes 
hand in hand with the increase and amelioration of the disease. 

Relapsing fever is in reality a filth disease. It has been ob- 
served chiefly in Ireland, on the European continent, and in 
India. It first made its appearance in the United States in 
1844, and during its last visit (1869), which, like former inva- 
sions, was due to immigration, was studied in New York and 
Philadelphia. It is undoubtedly contagious, although much 
less so than t\ r phus, for the observance of cleanliness alone 
affords protection against it. Age and sex are no factors, and 
one attack does not give immunit}- from subsequent attacks. 

Symptomatology. — The onset of the disease is usually sudden. 
A chill, more or less severe, is quickly followed by high fever 
and severe constitutional symptoms, as great exhaustion, 
severe headache, occasionally delirium, loss of appetite, heavy 
and distressing aching and pain in the loins and extremities, 
with great soreness on touch. The temperature increases rap- 
idly from the first, and within twenty-four or forty-eight hours 
may reach 106°, or more, the pulse ranging from 110 to 130. 
There is pungent heat of the skin, which is almost alwa3^s of a 
dirty, jaundiced hue. The tongue is dry and thickly coated ; 
the bowels are constipated, slightly loose. Great enlargement 
of the spleen, surpassing that of typhoid fever, is observed earl y ; 
there is moderate enlargement of the liver, bronchial catarrh, 
apatlry and mild stupor. The fever continues for five to seven 
clays, often with morning remissions, which may be quite 
marked, the temperature not infrequently sinking to normal, 
and even lower, to return to its full marking in the evening. 
These remissions are more frequent and more pronounced to- 
ward the end of the first week than during the first few da^-s. 
At this time a crisis occurs, quite often preceded b\ r an unusual 
rise in the temperature on the preceding evening (perturbatio 
critica) and by copious sweating, a return to normal or 
slightly subnormal temperature, followed by relief of all the 



RELAPSING FEVER. 47 

constitutional symptoms, with a decided feeling of well-being. 
In rare cases the course of the disease terminates here. Usu- 
ally, however, on the fourteenth day a chill again appears, fol- 
lowed by the same train of symptoms ; it continues for nearly 
the same number of days, and again passes off by crisis. If a 
-third attack occur, it will be shorter than its predecessors, 
presenting the same general characteristics. Occasionally, 
though rarely, there is a fourth and a fifth attack, but they are 
progressively lighter, and not often continue more than one or 
two days. 

The highest temperature observed by Struempell at the Leip- 
zig hospital was 107.9°, with an average of from 105.5° to 
106.3°. The fall in the temperature following the crisis is 
great, not infrequently from nine to ten degrees ; at Leipzig one 
case was seen in which it dropped to 92.1°. During the inter- 
vals slight elevations of temperature may occur as evidence of 
some constitutional irritation ; a decided rise may precede the 
chill which marks the appearance of a relapse. 

Complications are comparatively rare. In Germany epistaxis 
is common ; haemorrhagic nephritis and pneumonia are not 
rare ; affections of the eye, especially iritis and iridochoroiditis, 
have also been observed. Abortion in pregnant women and 
post-febrile paralyses occur as sequels. 

Variations from the course as described depend chiefly upon 
unusual mildness or unusual severity of the attack. Griesinger 
has written interestingly upon the "bilious typhoid" as it is 
observed in Egypt ; it is a dangerous form of relapsing fever, 
with grave nervous symptoms, severe jaundice, haemorrhagic 
tendencies, and frequently fatal termination. The spirilli are 
always present, and inoculation with them reproduces the 
disease. 

Morbid Anatomy. — Struempell describes as especially im- 
portant and characteristic "wedge-shaped white spots in the 
spleen" "like infarctions," which "become the starting point 
of pyaemic conditions or of peritonitis." Enlargement, with 
softening, is found in the spleen and liver; the kidneys and 
heart may be soft and swollen. Ecchymoses are sometimes 
seen. 

Prognosis. — The rate of mortality during the last century 
was high ; under modern treatment the prognosis is favorable. 



48 SPECIFIC INFECTIOUS DISEASES. 

During the last epidemic in Germany from two to four per 
cent, of all the cases terminated fatally, usually from pneu- 
monia or nephritis. 

Treatment. — An abundance of good, nourishing food and 
fresh air is of great importance. The severe muscular soreness 
and sensitiveness to touch renders the bath impracticable, and 
may have to be relieved by the use of chloroform liniment. It 
is of interest to know that quinine and salicylic acid, given per- 
severingly and in large closes, have utterly failed to affect the 
course of the disease or to prevent the recurrence of the 
paroxysms. 

Therapeutics. — Aconite is a valuable remedy during the 
first twenty-four or forty-eight hours; Baptisia with its "tired, 
bruised, sick-feeling all over," dull, stupid headache, and pecu- 
liar torpor and characteristic nervous symptoms, will be use- 
ful later. — Gelsemium is indicated by great languor, weariness, 
indifference, desire to be let alone. Dull, heavy expression of 
the countenance with, often, drooping of the eyelids; fever 
without thirst. Great weakness of the legs; drowsiness; 
wants to be still and sleep all the while during the day and in 
the morning. Hard aching in sacro-iliac and lumbar regions, 
running down into the thigh. Chilliness, with cold extremities 
and heat of the head and face. Constant perspiration, with 
languor and prostration ; fever, followed by long-continued 
sweat, which comes on gradually and gives great relief, or by 
moderate sweat with copious emissions of clear, limpid urine. — 
China officinalis is indicated by the clear-cut periodicity of 
the disease; jaundice, enlargement of spleen and liver; cachexia 
and great exhaustion. The relation of China to conditions 
characterized by anaemia or depending upon a low, depraved 
state of the system is also to be remembered. — Eupatorium 
perfoliatum. Bruised, sore pains in the back and limbs, 
severe bone-pains and headache, with internal soreness. Great 
soreness in the liver and epigastrium, with tenderness to pres- 
sure ; sallowness of the skin ; thick, heavy coating of the tongue, 
with much thirst and vomiting after drinking. — Arnica, Mer- 
curius (characteristic coating of the tongue; enlargement and 
sensitiveness of the liver; pains in bones and joints, worse at 
night and from warmth of bed; icterus), Phosphorus, Phos- 
phoric acid, and Berberis (enlargement of the spleen) and 
the remedies given under typhoid and typhus fever should be 
considered. 



YELLOW FEVER. 49 



YELLOW FEVER. 



(Black Vomit —Yellow Jack.) 

An acute infectious, non-contagious disease, originating in 
tropic countries, characterized by fever, jaundice, black vomit, 
and rapidly developing and profound prostration. 

^Etiology. — It is conceded that yellow fever is due to a micro- 
organism which has not yet been isolated. The fever is endemic 
in the West Indies and other tropic countries, but in the course 
of ocean travel is carried to temperate zones, where it may be- 
come epidemic. It cannot exist in the frigid zone, and the 
advent of frost in any country suffering from it invariably 
affords relief. However, the experience had, among others, at 
Memphis (1879) demonstrates how tenacious of life is this 
specific germ, and its ability to hibernate and under proper 
conditions to reassert its virulence with the return of warm 
weather. 

The disease for its development requires moisture and a tem- 
perature of about 75° F. It is conveyed by fomites, baggage, 
bedding, clothing, merchandise, and frequently by means of 
the bilge water of infected ships. It thus invades seaport 
towns and readily assumes the form of a local epidemic. The 
conditions which are favorable to its spreading are those found 
in large cities, as overcrowding of population and neglect of 
sanitary arrangements, lack of cleanliness, etc. The poor- 
quarters of a large city, in which such conditions are most pro- 
nounced, readily become the hotbed of the fever. Yellow fever 
prefers seaport towns and a low elevation, not to exceed 750 
feet ; yet, it has been known to travel inland, generally along 
the course of navigable rivers (Quebec, Portsmouth, N. H., 
1798 ; Cincinnati and Gallipolis, 1887), and even to infect high 
mountainous regions. In Havana it is most active in June, 
July and August; in this country it appears in late summer and 
early autumn. The average duration of an epidemic is from 
six to eight weeks. 

The virus keeps near the ground, and resembles malarial 
poison in that it is more effective during the night than during 
the day. Malarial and typhoid fever are prevalent during 
4 



50 SPECIFIC INFECTIOUS DISEASES. 

epidemics of yellow fever, but do not occur together in the 
same individual. 

No sex, age, or race is exempt. That men more frequently 
than women become its victims depends undoubtedly upon 
more constant exposure to the poison ; it is stated that males 
between the age of twenty and forty years furnish the larger 
number of fatal cases, and that the very young and the aged 
more readily escape, probably because they are less frequently 
exposed ; but neither extreme of life confers immunity. During 
severe epidemics a high rate of mortality has been observed 
among children less than five years of age. Negroes are less 
liable to infection than whites. 

Long residence in a city which has been, or is, infected, 
affords a considerable degree of immunity; the unacclimated 
suffer severely, as forcibly illustrated in the Memphis epidemic 
of 1878, during which of the fifty-five unacclimated physicians 
who went there for the relief of the people, fifty -four had the 
fever. One attack, as a general rule, affords immunity from 
future attacks, but instances are on record where the disease 
occurred twice in the same person. 

Fear, overwork, careless and irregular living, exposure, and 
all agents which lower vitality" and the powers of resistance, 
may be classed among the predisposing causes. 

Morbid Anatomy. — The internal organs present no charac- 
teristic changes ; hyperemia, hemorrhagic extravasations and 
degenerative processes are present. Skin: jaundiced (hemato- 
genous). Blood : dark, coagulates poorly, decomposes quickly ; 
disintegration of red corpuscles. Liver: friable, in color from a 
pale yellow to an orange hue, with evidence of fatty degenera- 
tion and areas of necrosis. Kidneys : diffuse nephritis, cloudy 
swelling of epithelia of the convoluted tubes, with granular 
fatty degeneration. Alimentary canal: catarrh, with soften- 
ing and ecchymotic condition of the gastric walls, the stomach 
as well as the intestine containing large amounts of black 
vomit. Fatty degenerative changes in the heart are not un- 
usual. The icteric condition is general, as are also the hemor- 
rhagic extravasations, which are seen especially on the serous 
and mucous membrane. 

Symptoms. — The stage of incubation continues from two to 
four days, or longer; there may be malaise, headache, back- 



YELLOW FEVER. 51 

ache, loss of appetite and sense of prostration ; again, a slight 
indisposition, with some weariness, may constitute the only 
deviation from health. 

The disease proper presents three stages: 1) the paroxysm; 
2) the remission ; 3) the reaction and collapse. 

The Paroxysm. — A violent chill suddenly sets in, accompanied 
with frontal headache, rheumatoid pain in the back and ex- 
tremities, most severe in the legs and loins. There is vomiting 
and great prostration. Capillary congestion is marked, giving 
the patient an almost typical expression. "The dusky face 
with the deep suffusion of the eyes, in severe cases, is quite 
characteristic" (Sternberg). The eyes are congested, staring, 
sensitive to light. There may be sweating. 

The cold stage having passed, fever follows, rising rapidly ; 
the skin is hot and dry, the face flushed, the tongue furred, but 
moist, and there may be sore throat. The stomach is irritable, 
and soon vomiting sets in, first of mucus, then of bile, and at 
times of blood ; the vomiting is violent and is readily pro- 
voked by pressure on the pit of the stomach. The mouth is 
dry, the gums sensitive and swollen, the bowels constipated, 
the urine scanty and albuminous from the start or after the 
second or third day. The skin may be hot and dry, or bathed 
in profuse, sticky perspiration; there is considerable restless- 
ness, sometimes delirium. Jaundice appears on the third or 
fourth day, first in the conjunctiva, later it becomes general. 
The pulse, in proportion to the fever, is rather slow, rarely 
more than 110 beats per minute; it is feeble and compressible. 

In children this stage may be ushered in by convulsions ; 
sometimes there is no initial chill or cold stage. 

This first, febrile, stage continues for two, or more, days; 
then the symptoms abate, and the Stage of Remission, or the 
Calm Stage, is reached. The temperature of the body now is 
normal or subnormal. There is considerable prostration, but 
the patient appears convalescing; and, in fact, in light cases 
convalescence begins here. More often, after a few days, some- 
times after only two or three hours, the symptoms again in- 
crease in severity, the jaundice deepens, the urine grows more 
scanty, and The Stage of Febrile Reaction, or of Collapse, 
begins. The temperature rises again, reaching 103° or 104° ; 
jaundice continues in an aggravated form; the secretion of 



52 SPECIFIC INFECTIOUS DISEASES. 

urine is arrested, and there are passive haemorrhages from the 
mucous membrane. In some cases, with the development of 
these serious symptoms, the pulse-rate drops, possibly to forty 
beats per minute. The most constant expression of this 
haemorrhagic tendency is the "black vomit." It is at times 
accompanied with much abdominal distress and consists chiefly 
of blood which oozes from the capillary walls of the congested 
and softened gastric mucous membrane and has been acted 
upon by the acid gastric juice of the stomach. In appearance 
it resembles coffee-grounds ; it is made up of altered red blood 
corpuscles, epithelial cells, degenerated mucus, pigment, leu- 
cocytes, fatt} r matter, portion's of food, and serum ; it also con- 
tains various fungi. It is acrid, irritates the fauces, and in 
amount varies from a few drachms to several pints. Excep- 
tionally ' ' black vomit ' ' is not present, but even in such cases 
examination after death usually shows its presence in the 
stomach and in the intestine. It is observed in nearly all fatal 
cases, but does not in itself determine a fatal issue of the case. 
In the same manner passive haemorrhage occurs from the 
intestinal walls, giving rise to tarry, black, diarrhceic stools. 
Bleeding may also take place from the nose, ears, respirator}' 
and urinary mucous membrane, and from the vagina and 
uterus. Pregnant women almost always miscarry. 

The icterus in this stage ma}- be intense, giving to the body a 
dark mahogany color, staining the perspiration and urine ; it 
is due to a disorganization of the liver and reabsorption of bile. 
The urine is acid, of high specific gravity, deficient in chlorides 
stained by altered blood pigment, and contains granular and 
hyaline casts. If suppressed, uraemia will probably still further 
aggravate the already serious condition of the patient. If the 
patient recovers, the jaundice and other s\ r mptoms improve, 
with an average duration of the disease of six day-s. If the 
termination is fatal, a typhoid state may develop after the 
fourth day with deepening of jaundice, continued black vomit, 
muttering delirium, urinary suppression, at times convulsions, 
usually coma and death. In some cases delirium is not pro- 
nounced, but there exists a semi-consciousness of all there is 
going on, with a striking apathy and indifference. Haemor- 
rhage alone may prove fatal at any period of the disease, or a 
fatal collapse may suddenly occur, even in cases where the 



YELLOW FEVER. 53 

patient is about, seemingly in no danger or quite well. Re- 
lapses are always to be dreaded. Death commonly takes place 
from the third to the fifth day of the disease. 

Varieties. — At times the initial chill is wanting and the 
disease begins with fever ; in others, there is no reaction after 
the cold stage has passed, the skin becomes livid, the pulse 
feeble, there is albuminuria, coma and death takes place on the 
second or third day ; again, delirium and mania may initiate 
the attack, and constitute grounds for a very serious prognosis. 
The natural subdivision is into the light cases which, in the 
absence of an epidemic, easily escape recognition because of the 
derth of pathognomonic symptoms ; second, the severer form, 
in which fever, jaundice and black vomit are present; and, 
third, the malignant form, which terminates fatally -within a 
few hours or from two to three days. 

Diagnosis. — In light cases the diagnosis may present serious 
difficulties, except as the presence of an epidemic or the exist- 
ence of other grounds of suspicion may throw light upon the 
nature of the case. The diagnostic points are the existence of 
the disease in the community or knowledge of its importation, 
albuminuria, fever, icterus, and black vomit. 

Light cases resemble malarial fever; the salutary effect of 
quinine, the enlargement of spleen, the distinct periodicity of 
the fever, the absence of albuminuria and of black vomit, prove 
the malarial character of the fever. Dengue fever has the 
characteristic and persistent pains, and frequently is of a dis- 
tinctly remittent character. Typhoid fever, relapsing fever, 
local jaundice, acute yellow atrophy, and other affections 
which present isolated points of similarity to yellow fever not 
only lack its specific astiological factors, but differ from it suf- 
ficiently in their clinical history to allow a ready diagnosis. 

Prognosis. — The prognosis must always be guarded. The 
mortality in various epidemics differs greatly, ranging from 15 
to 80 per cent. It is greatest during the height of epidemics, 
severest among the improvident classes, hard drinkers, bad 
livers, and among persons who are exposed to hard labor, 
■worry, or are generally debilitated. Persons not acclimated 
fare badly ; plethoric people are said to be unpromising cases. 
Results in private practice are much better than those obtained 



54 SPECIFIC INFECTIOUS DISEASES. 

in public institutions. Three-fourths of the deaths occur in the 
first week of the disease. 

Favorable symptoms are: low fever; temperature below 
103.5°; slight jaundice; slight hemorrhagic tendenc}^ ; moder- 
ate albuminuria ; comparatively free secretion of urine. Unfa- 
vorable S3^mptoms are: unusual violence of the initial par- 
oxysm ; copiousness of black vomit and unusually pronounced 
hemorrhagic tendency; early and intense jaundice; pregnant 
or puerperal state ; suppression of urine ; excessive and early 
capillary congestion ; marked brain symptoms ; embarrassment 
of respiration and of the heart's action. 

Treatment. — Prophylaxis. — " Isolation, disinfection, depopu- 
lation " have justly been said to be the summing-up of the pro- 
phylaxis of Yellow Fever. Ship quarantine is of the greatest 
importance, because, effectively maintained, it affords the only 
means of protection against importation of the disease from 
foreign parts. The establishment of sanitary cordons (as in 
Texas, 1882, and in Georgia, 1893), and of Camps of Proba- 
tion or Detention (as Camp Mitchell during the Memphis epi- 
demic of 1879, Camp Perry, in Florida, 1888 ; at Waynesville, 
Georgia, in 1893), not only greatly reduce danger of importa- 
tion, but afford the best means of prompt recovery to persons 
already endangered by exposure. 

The necessity of thorough disinfection of all articles which 
may become disease carriers, and of persons exposed, also of cor- 
recting sanitary conditions in localities invaded or threatened, 
is self-evident; the means of accomplishing this have been 
discussed. Depopulation is accomplished by prompt removal 
of those not yet sick and who can be spared from attendance 
upon the sick, to favorable localities, especially to camps prop- 
erly situated, where they can live a simple, well regulated out- 
of-door life. Where duty makes such a removal impossible, 
careful attention must be given to the maintenance of good 
health ; unnecessary exposure, as visiting the infected portions 
of a city, and all excesses, worry, and special drafts upon the 
vital forces must be avoided. 

The treatment of the patient requires promptness of action 
and skill in meeting emergencies. The use of hot water during 
the pyrexia is grateful and effective; sponging in tepid, cold 
and hot water has been practiced with good results. Shaved 



YELLOW FEVER. 55 

ice may relieve thirst and vomiting. Emergencies must be 
met as they arise. Abstinence from food is urged by physi- 
cians of large experience, absolutely so during the first stage ; 
when feeding is resumed, it should be done with the utmost 
care ; at first meat broths in small amounts may be given, 
closely watching the effect ; the patient must not be allowed to 
raise his head from the pillow. Feeding per rectum may be^ 
come necessary at any time, and has given satisfactory results. 
Beer and champagne are said by some observers to have been 
borne well in all stages of the disease. 

Therapeutics. — Falligant, an eminent Southern physician 
of extensive experience in the treatment of yellow fever, recom- 
mends in the first stage : Aconite, Belladonna, Ipecacuanha, 
China, Nux vomica ; in the second stage : Belladonna, Bry- 
onia, Arsenicum, Nux vomica, Sulphuric acid, Plumbum 
aceticum; in the third stage: Sulphuric acid, Arsenicum, 
Crotalus, Lachesis, Argentum nitricum, Phosphorus, 
Carbo vegetabilis. 

Aconite. —In the first stage and for a short time only, with 
the usual characteristic symptoms ; nausea and vomiting, heat 
in the stomach, anxious breathing, pain in the region of the 
heart ; pain in the back and extremities. Falligant advises a 
solution of five drops of the tincture in six ounces of water in 
alternation with Belladonna, similarly prepared, every half- 
hour until the fever has declined, probably for twelve to twenty- 
four hours, with hot mustard foot-baths every six hours. — 
Belladonna. Characteristic heat, redness of face, sharp, shoot- 
ing, throbbing (frontal) pains in the head and ears. Symptoms 
of active congestion. Dry, hot tongue and throat. Nausea 
and violent vomiting. Burning and throbbing in the pit of the 
stomach. Head and body hot, feet cold. Urine red or brown. 
Later, characteristic cerebral symptoms, delirium, cystic haem- 
orrhage, convulsive action, swelling of the glands. Typhoid 
state. Glandular affections during convalescence. — Ipecacu- 
anha. Gastric symptoms, as nausea and vomiting, with pro- 
nounced aversion to food. Constant feeling of sickness at the 
stomach, with great relaxation of the system and weakness. 
Vomiting of black, pitch-like masses. — China. Diarrhoea most 
prominent, with weakness and debility; profuse, frequent, 



56 SPECIFIC INFECTIOUS DISEASES. 

putrid, dark, painless. Copious emissions of flatus, without 
relief. Typhoid condition. — Bryonia. Occipital headache, ex- 
tending down the neck and shoulders, worse from motion; 
general muscular soreness all over, especially in the back ; pain 
in the eyes when moving them ; burning thirst, with aggrava- 
tion of the gastric symptoms from drinking; fulness and op- 
pression in the pit of the stomach and bowels ; sharp, stitching, 
pleuritic pains. Icterus. Anxiety and fear about the future. 
Typhoid condition. — Arsenicum. Great thirst, wanting to 
drink often and small amounts at a time, with increased 
gastric distress and vomiting after drinking. Vomiting 
of watery, then bilious, then dark, black, coffee-ground sub- 
stance. Pressive, burning pain in the pit of the stomach ; 
cramps in the bowels ; painless, watery, or involuntary diar- 
rhoea ; diarrhoea of dark, offensive stools ; oppression of the 
chest; suppression of urine; irregular, small, rapid, trembling 
pulse. Internal heat and external coldness. Coldness of the 
body to touch, with sticky, clammy perspiration. Great 
anxiety and restlessness. Face haggard, yellowish, livid, or 
deep, dull red. Eyes dull and sunken; nose pointed. Hippo- 
cratic countenance. In the second stage, when gastric symp- 
toms continue. Haemorrhage, uterine or cystic. Typhoid 
form. — Crotalus. Neidhard, and others, have called attention 
to the value of the snake poisons, suggested largely by their 
action upon the blood and their close relation, homoeopathically , 
to hemorrhagic states. Cinical experience with both Crotalus 
and Lachesis has been extensive and satisfactory. The indica- 
tions furnished by the Yellow Fever Commission are : delirium 
with open eyes ; utter apathy ; confused speech ; disconnected 
answers, with coldness of the skin and rapid pulse ; terrible 
headache, with red, puffed face; face yellow, sometimes of a 
leaden color ; blood flows from the eyes, ears, and nose, indeed 
from all the orifices of the body, even bloody sweat ; thirst ; 
sour, acrid eructations ; scraping, rancid sensation clown the 
oesophagus to the stomach ; extreme nausea and vomiting 
from the least exertion ; vomiting of bile, of blood ; swelling of 
the whole abdomen ; enlargement of the inguinal glands ; 
bloody stools, sometimes involuntary; haemorrhage from the 
urethra ; painful retention of the urine ; menses anticipate ; 
hoarse, weak, rough voice; pains in chest; pulse slower than 



YELLOW FEVER. 57 

natural (sixty beats) or intermitting and scarcely perceptible ; 
pains in bones; deep yellow color of the whole body ; purple 
spots ; extreme depression of the vital powers ; spasms ; death 
by syncope; acts more on right side. — Argentum nitricum. 
Holcombe recommends it in the later stage, especially for the 
relief of the black vomit "when other remedies have failed to 
reach it. Hardenstein advises its use when there is much brain 
irritation, with violent headache, vertigo, sharp pains in the 
head extending from the occiput forward, with bending the 
head backward. — Lachesis. Delirium at night; loquacious, 
disposed to quarrel ; slow, difficult speech ; drowsy ; rush of 
blood to the head ; red face ; yellow conjunctiva ; yellow or 
purplish tint of skin ; blood dark, non-coagulable ; small wounds 
bleed much ; perspiration stains yellow ; lips dry, cracked and 
bleeding ; tongue heavy, trembling, dry and red, cracked at the 
tip ; tip red, center brown ; difficult speech ; sour eructations ; 
heartburn ; nausea after drinking ; vomiting, with palpitation; 
dyspnoea ; anxiety about the heart ; cannot lie on left side; irreg- 
ular, weak pulse ; urine almost black ; persistent sleeplessness; 
fainting, trembling all over ; sudden flushes of heat ; sensitive- 
ness about the neck and pit of the stomach against any pres- 
sure ; worse when waking ; better after nourishment ; acts more 
on the left side. — Nux vomica is of value during convalescence, 
when there is a tendency to constipation. — Mercurius solu- 
bilis may be useful if biliousness and irritability of the stom- 
ach remains.— Hyoscyamus, Opium, Stramonium, and others of 
this class, if brain symptoms (convulsions) predominate. — 
Typhoid symptoms, in addition to Arsenic, Bryonia, Crot- 
alus and Lachesis may point to Baptisia, Cimicifuga, Rhus 
tox., Sulphuric acid. The latter has the hasmorrhagic ten- 
dency, great prostration, rapid sinking, thick, soft pulse, general 
trembling, vomiting, and diarrhoea of an extremely fetid char- 
acter. It has proved of value in several epidemics. The pure acid 
should be used in sufficient strength to slightly acidulate the 
water. Urinary suppression may demand the exhibition of 
Cantharides, which Holcombe, and others, found quite relia- 
ble. — Collapse may warrant the use, in addition to stimulants, 
of Camphora, Carbo veget., possibly Aconite. — Cuprum is 
said to follow Arsenic and to be an excellent remedy for black 
vomit. Falligant claims that the only remedy he has ever 



58 SPECIFIC INFECTIOUS DISEASES. 

known to do any good in suppression of urine was a mixture 
of a teaspoonful of Nitre, ateaspoonful of Gin, and a wineglass- 
ful of watermelon-seed tea mixed, given at one dose. "Three to 
four successive doses secured a resecretion of urine in several of 
my latest black vomit cases in 1876, the previous emptiness of 
the bladder being unquestionably proved by tests "with the 
catheter." 



MALARIAL FEVER. 

Synonyms: Paludal fever. — Ague. — Fever-and-ague ; — Marsh 
fever. — Swamp fever — Intermittent fever. 

A type of fever characterized by marked periodicity, with in- 
tervals of freedom from specific symptoms, manifesting itself 
in forms which greatly differ in their clinical history and 
gravity, but are always accompanied by the presence of a 
vegetable micro-organism (the haematozoa of Laveran) in the 
blood. 

^Etiology. — Malarial fever is endemic in all regions and coun- 
tries save the frigid zone. It is most frequent and malignant 
in tropical and subtropical countries, where the conditions 
essential for its development, i. e. heat, moisture, and rank 
vegetable growth, are most fully met ; its distribution, how- 
ever, in temperate climates is very extensive. It abounds in low, 
swampy grounds, with abundant vegetation, estuaries, and 
salt-water, swamps, badly drained lands, particularly in low 
swampy grounds once cultivated but allowed to relapse, and 
in low lands after a recent overflow. It has also developed in 
the bilge water of ships at sea. Places are, however, known 
which meet all the conditions and are yet free from malarial 
fever ; such are the marshy districts of Ireland and the lake of 
Tescudo, in Mexico. 

The disease may also develop in persons who have left a 
malarious region and have settled in a country where malarial 
fevers occur never or very rareh', and in those who visit the 
seashore after having for years lived inland in malarious dis- 
tricts. 

In tropical countries it is most common in autumn, less so in 



MALARIAL FEVER. 59 

spring ; in temperate regions it shows a preference for Septem- 
ber and October, including early November. Extremely dry or 
extremely -wet weather appears to check it in temperate coun- 
tries. 

The miasm itself is of low specific gravity, hence does not 
readily rise beyond a certain height; to this fact is due the 
comparative safety insured by sleeping in the upper story of a 
house and by building on high ground. It is abundant in the 
lower atmosphere and is carried on currents of air ; exposure 
to such miasm-laden winds results in outbreaks of fevers on 
part of those exposed to them, as in the Roman Campagna. 
It is especially active at the time of sunrise and sunset. Ex- 
posure to draughts of cold air, in tropical countries, after being 
out in the hot sun, is known to have precipitated an im- 
mediate attack of the fever. 

A low altitude is generally associated with malarial in- 
fluences, but malaria also exists in high elevations. 

Sex, age or race have no bearing upon the aetiology of 
malaria. It is not proved that negroes are less liable to it than 
the Caucasian race, save as in accordance with the operations 
of the law of acclimatization. Men furnish a larger number 
of these cases than do women ; this fact undoubtedly is due to 
greater and more frequent exposure of men while at work in 
marshes and other malaria-infected places. 

The malarial parasite, extensively studied by Laveran and 
others, is a vegetable micro-organism found in the blood of 
man and of some of the lower animals ; it occurs in abundance 
during malarial fever, and at no other time. It enters the 
system with the inhaled air and through the alimentary canal, 
chiefly with the drinking-water. A temperature of not less 
than 60° F. appears necessary to its existence. 

Various forms of the haematozoa are seen in the blood of 
malarious patients, and these are closely connected with the 
different manifestations of the poison and the particular form 
of the disease produced. "Golgi has described two distinct 
forms which he considers the cause of tertian and quartan 
fevers, and makes all other types depend on combinations of 
these. This probably holds good for a large proportion of 
intermittents. With the remittents, Marchiafava and Celli 
have described a distinct species, and look upon the crescents as 



60 SPECIFIC INFECTIOUS DISEASES. 

representing a phase in its development. The pernicious 
malarial fevers are also associated with this variety, which the 
Italian observers call the 'small plasmodium.' The crescents 
may occur also in acute cases, but are most constant in malarial 
cachexia. The flagellate bodies do not appear to have any 
definite relation to the different forms of the disease." "The 
general symptoms and the morbid anatomy of malaria are in 
harmony with the changes which this parasite induces. The 
destruction of the red blood-corpuscles by it can be traced in 
all stages. The presence of the pigment in the blood and in the 
viscera, so characteristic of malaria, results from the trans- 
formation of the haemoglobin by the plasmodia. The anaemia 
is the direct consequence of the wide-spread destruction of the 
corpuscles by the parasites. The constancy of their presence, 
the fact of their causing rapid destruction of the red blood- 
corpuscles, and the remarkable coincidence of their disappear- 
ance contemporaneously with the symptoms of the adminis- 
tration of quinine, are points strongly in favor of their aetio- 
logical relation with the disease. There are still many gaps in 
our knowledge. We do not know how the parasite enters, or 
how or in what form it leaves the body ; how and where it is 
propagated ; under what outside conditions it develops, 
whether free or in some aquatic plant or animal. No record 
of its successful cultivation has been published." (Osier.) 

Although in all forms of malarial poisoning the essential 
cause is the same, it is practical to recognize certain clinical 
types of which the following are especially important : inter- 
mittent fever, remittent fever, pernicious malarial fever, and 
chronic malarial poisoning. 

INTERMITTENT FEVER. 

Morbid Anatomy. — The most important changes are as fol- 
lows : spleen : engorgement and enlargement during the fever, 
which at first disappears during the "interval" (/. e. the time 
which intervenes between the beginning of one parox3^sm and 
that of the next), but eventually may become permanent 
(" ague-cake"), and which ma_v be sufficient to cause the organ 
to extend as low as the umbilicus. The size of this enlarge- 
ment does not necessarily depend upon the duration of the 
disease. In very rare cases rupture of the spleen, spontaneous 



INTERMITTENT FEVER. 61 

or from traumatism, may occur, with fatal haemorrhage into 
the peritoneal cavity. Liver: enlargement and tenderness 
upon pressure. Blood: lessening of the number of red and 
white corpuscles. 

Clinical History. — The period of incubation usually is from 
seven to fourteen days ; in exceptional cases the first symptoms 
show themselves within twenty-four hours after exposure; 
again, a person may have been exposed to malarial influences 
for a great length of time, and not have intermittent fever until 
removal to some non-malarious country. This form consists 
of regularly recurring paroxysms of chill, fever, and sweating, 
which follow each other, at times with clock-like regularity. 

The chill, or cold stage. Its onset is gradual or sudden. If 
gradual, there is usually some indisposition, possibly a vague 
sense of coldness and a dull headache, with lassitude. By de- 
grees the chilliness increases ; it is most noticeable, often, in the 
back and loins, and from there extends all over the body. 
There is yawning, stretching, bitter taste in the mouth, pale 
coated tongue, and increasing headache. Eventually, in the 
typical case, the chill becomes pronounced ; the teeth chatter ; 
there is great pallor of the face, which looks haggard and 
sunken ; the surface of the body feels cold to the touch and is 
pale, dry and rough ("goose flesh" or cutis anserina); the 
patient vainly endeavors to find relief from the intense coldness 
by the use of any and all covering within reach. The muscular 
rigors are often so severe as to shake the bed ; the tips of 
fingers, ears and nose are livid; the voice is husky and faint; 
respiration is hurried and often labored; the pulse is quick, 
small and hard ; contraction of the peripheral vessels causes 
vascular congestion of the viscera, enlargement of the spleen, 
with tenderness on pressure in the region of the spleen and 
liver. The surface temperature is reduced, but taken in the 
rectum or axilla the thermometer may register 104° to 106° F., 
the fever not infrequently almost reaching the maximum point 
during this stage. In severe cases symptoms of collapse may 
appear. If the onset of the cold stage is sudden, the chill 
develops rapidly and usually is severe, resembling the chill of 
croupous pneumonia and of cerebro-spinal meningitis. The 
cold stage continues for ten or fifteen minutes to an hour, and 
longer. 



62 SPECIFIC INFECTIOUS DISEASES. 

The hot stage begins with a lessening of the intense coldness 
and with transient, comforting flashes of heat. The peripheral 
vessels relax, the blood returns to the surface, relieving the con- 
gested inner organs, and the face flushes. The surface of the 
body becomes burning hot, smooth, dry, red. The throat is 
parched, and large draughts of cold water are eagerly taken; 
the lips are often blistered, the tongue heavily coated, the 
breath foul ; there may be nausea and vomiting ; the patient 
suffers from severe throbbing frontal headache ; the pulse is full 
and bounding, 120, or more, beats to the minute, sometimes 
dicrotic. There frequently is intense restlessness and irrita- 
bility, but rarely delirium, save in children. Dizziness, ringing 
in the ears and muscas volit antes may be present. The tem- 
perature remains high, possibly reaching 106°, or even more, 
though not infrequenth^ there is onh^ slight increase — from 0.5° 
tol.° — over the maximum temperature reached during the cold 
stage. 

This stage lasts from one to several hours, rarely more than 
five or six. 

The stage of sweating appears with moisture on the fore- 
head and face, gradually and often rapidly involving the entire 
surface ; it culminates in a profuse, drenching sweat, accompa- 
nied by relief of all the symptoms, the patient, in a majority of 
cases, droppinginto a quiet, restful sleep from which he awakens 
greatly refreshed. This stage lasts from two to four hours, or 
longer. 

During the intermission between the paroxysms the patient 
ma3 r be about as usual, but slightly indisposed. 

In the intermittent fever of children the hard chill and shak- 
ing are generally absent, dulness, drowsiness, and coldness of 
the surface, with coldness and lividit} r of the face and extremi- 
ties, supervening. The hot stage in most cases is well pro- 
nounced, and there is a tendency to convulsive action and even 
coma. The sweating is not prolonged or severe, and may even 
be wholly wanting. Bronchitis, more often than in adults, 
complicates the fever. 

The temperature of intermittent fever may be very high, 
remaining so for some hours, without causing alarm. Parke 
(Personal Experience in Equatorial Africa) is frequently quoted 
as statins that he has seen everv officer in the Emin Pasha 



INTERMITTENT FEVER. 63 

relief expedition march all day -with temperature of over 105° 
F. The temperature rises more rapidly than it falls, continues 
at its maximum for one to three, or more, hours, and declines, 
sometimes uniformly, but often one or two degrees at a time, 
remaining stationary for a half hour or more, then to fall 
again, and eventually reaching a subnormal condition (from 
one to one and a-half degrees below normal). The urine, dur- 
ing the cold stage, is frequently increased in amount and loaded 
with waste products. The excretion of urea is greatly stimu- 
lated during the paroxysm ; it is, indeed, observed for two 
hours before the chill, thus affording a clear-cut indication as 
to the precise time when quinine should be given for the pur- 
pose of anticipating the chill. 

Types and Variations. — The paroxysms nearly always occur 
with remarkable regularity, either at the end of 24, 48, or 72 
hours. If occurring at the expiration of 24 hours from the 
beginning of the preceding paroxysm, the fever is said to be of 
the quotidian type, a common type of intermittent fever. If 
the "interval" is 48 hours, the paroxysm occurring every 
third day, the fever is of the tertian type, — a common type. 
If the interval is 72 hours, the paroxysm recurring on the 
fourth day, it is a "quartan" fever, — a type much less fre- 
quently seen. 

Usually the paroxysms appear at the same hour, in the 
quotidian and tertian type in the forenoon; in the quartan 
type, shortly before noon or in the afternoon. The intervals, 
however, may be shortened or lengthened, thus giving rise to 
the "anticipating", and "retarding" or "postponing" form; 
if the paroxysm is "postponed," the disease is growing lighter. 

All these types may be duplicated in the same person, and we 
may thus find, for instance, a double quotidian fever, two dis- 
tinct paroxysms occurring during every 24 hours; or the 
various types may combine, giving rise to exceptional compli- 
cations in type, which, because of their infrequency , are of slight 
practical importance. 

Again, the stages of each paroxysm may not be equally pro- 
nounced. If there is no cold stage, the case becomes one of 
"dumb ague;" sometimes there is neither cold nor sweating 
stage. Or the stage may last so long as to have the last, the 
"sweating," stages, of one overlap the cold stage of the sue- 



64- SPECIFIC INFECTIOUS DISEASES. 

ceeding attack ; or neurotic symptoms, as neuralgia, may take 
the place of the cold stage ; or the malarial poisoning, though 
unmistakable, may give rise to general indisposition, with 
bilious symptoms, slight fever and great lassitude {latent inter- 
mittent fever), or to periodically recurring attacks of neuralgia, 
preferably of the supra-orbital or infra-orbital branch of the 
trigeminus (masked malarial fever), which takes the place of 
the regular paroxysm. 

Duration and Prognosis. — Intermittent fever, after a few 
paroxysms, may disappear of its own accord ; if so, it is liable 
to recur. As a rule, a favorable prognosis may safely be made. 
— There are found stubborn cases with great impoverishment 
of the blood and extensive destruction of the red blood cor- 
puscles by the parasite, leading to anaemia and jaundice. The 
possibility that a case may become chronic must also be kept in 
mind. 

Treatment. — The specific relation of quinine to intermittent 
fever is firmly established ; it is useless to deny its antagonism 
to the vegetable parasite or its power to destroy it. The posi- 
tion of the dominant school of medicine, therefore, is strong in 
the claim that the quinine-treatment is scientific. On the other 
hand, clinical experience, too extensive to be ignored, has 
shown that remedies homceopathically indicated are also cap- 
able of yielding good results, and that in many cases the treat- 
ment with quinine has in the long run proved much less satis- 
factory than the action of the homceopathically indicated and 
potentized remedy. 

If quinine is used, it should be used intelligently and with 
due care not to produce violent symptoms of cinchonism ; 
hence, the susceptibility of the individual to the action of 
quinine should be considered. The drug should be given in 
solution whenever the patient can bear it in this form ; if this 
is impracticable, wafers or gelatine capsules should be used. 
In small children, rectal suppositories or inunction of the 
abdomen with quinine-ointment, followed by energetic rub- 
bing, may be made to answer the same purpose. 

The majority of the clinicians of the dominant school, for 
good reasons, prefer one or two large doses "carefully timed so 
as to meet the paroxysm, so that one dose shall not be elimi- 
nated before the next exerts its influence" (W. G.Thompson) 



INTERMITTENT FEVER. 65 

to smaller doses distributed during the twenty-four hours ; 
thus, thirty to forty grains, four or five hours before the parox- 
ysm, are advised in a very severe case. Osier says, " The mode 
of administration is of little moment so the patient gets a 
sufficient quantity into his system. I have a number of charts 
showing that grain-doses three times a day will, in many cases, 
prevent the paroxysm, but not always with the certainty of 
the larger doses. It is safer to give at least from twenty to 
thirty gains daily for the first three days, and then to continue 
the remedy in smaller doses from two to three weeks." The 
quinine should not be administered during the paroxysm ; it 
then accomplishes nothing, and may greatly distress the 
patient; its maximum effect is not obtained until four or six 
hours after its administration ; hence, in the quotidian type it 
should be given eight hours, in the tertian twelve hours, and in 
the quartan type fifteen to eighteen hours, before the expected 
chill, and repeated. 

As a preventive for those obliged to visit malarial districts, 
quinine should be used three times daily in doses of from two to 
four grains. The bisulphate of quinia is a favorite now with 
many practitioners. 

The remedies which have proved most reliable when indi- 
cated homceopathically are : Eupatorium perfoliatum, Eupa- 

TORIUM PURPUREUM, GELSEMIUM, NUX VOMICA, CEDRON, IPECAC- 
UANHA, Quinine, China, Arsenic, Natrum muriaticum. 

Eupatorium perfol. The paroxysm usually occurs be- 
tween 7 and 9 o'clock a. m. It is preceded by great thirst, 
which continues throughout, but drinking provokes vomiting ; 
" bonepains " are very severe and persistent, hardest before the 
chill; great, general muscular soreness, especially of the eye- 
balls, head and chest; the gastric symptoms are severe through- 
out. The chill starts from the back ; the cold stage is persis- 
tent, the hot stage lighter, and sweating moderate. Loose 
cough during the intermission. I have verified Hale's state- 
ment that often a weak infusion acts promptly when the tinc- 
ture or the dilutions have failed. — Eupatorium purpur. The 
paroxysm comes on at different times in the day ; the chill is 
preceded by muscular aching in the extremities ; it begins in the 
small of the back ; "bone-ache," with deep aching and numb- 
ness of the legs; violent shaking, with comparatively slight 
5 



66 SPECIFIC INFECTIOUS DISEASES. 

actual coldness ; hot stage prolonged and marked ; sweating 
moderate and on the upper part of the body. During the inter- 
mission, dizziness, with sensation of falling toward the left side; 
dull pain in the kidneys ; frequent and painful desire to urinate, 
with weakness and faintness after urinating. — GELSEMIUM. 
Chill in the afternoon or evening, commencing in the hands or 
feet, running up the back; without thirst; at 10 a. m.; at the 
same hour of the day. Hands and feet very cold, with heavy, 
severe headache ; fulness in the head and sense of heat in the 
head and face. " Nervous chill." Hot stage marked and long- 
continued. Face looks congested, stupid, bluish; without 
thirst; wants to be let alone, unwilling to be disturbed. 
Wants to sleep; often slow to arouse from sleep. Sweat mod- 
erate, most profuse on the genitals. Tongue coated yellowish, 
pasty. Gastric symptoms not pronounced. After cessation of 
sweating he urinates often and freely; white limpid urine. 
Great exhaustion and muscular weakness during the apyrexia. 
— Nux vomica. The paroxysms are irregular, in the morning 
or late in the evening. The chill is hard, with blue face and 
nails, shaking, intense thirst, not relieved by drinking water. 
Severe ache in lumbar and sacral region, with paralytic numb- 
ness of the legs ; in the hot stage the thirst continues, the most 
characteristic feature, however, consisting of the patient's in- 
ability, in spite of the bodily heat, to have the covering 
removed, on account of the shivering which immediately 
seizes him ; he cannot bear to have the air touch him. Sweat- 
ing is commonly profuse and relieves the aching in the legs ; he 
must keep himself carefully covered up, as the air chills him. 
Gastric and bilious SA-mptoms are present throughout the 
paroxysms and the intermission, as : nausea, vomiting, ab- 
dominal uneasiness, colicky pain, constipation. Nux cases 
frequently have a great desire for beer, especially during the hot 
stage. Useful in "dumb ague," with "bilious" symptoms." An- 
ticipating" intermittents. — Cedron. Perfect regularity in the 
appearance of the paroxysms, the chill usually appearing about 
3 a. M. or 3 p. m. Preceded by mental depression and headache. 
Begins in the back, with icy coldness of hands and feet, made 
worse from the slightest motion ; the cold stage is well marked 
and accompanied with severe frontal headache. Heat with 
thirst for warm drinks ; numbness and weakness of the legs. 






INTERMITTENT FEVER. 67 

Copious sweating without thirst. The intermission is marked 
by great debility and general indisposition. The stages are not 
clear-cut, but overlapse ; the fever may be ushered in with an 
attack of supra- or infra-orbital neuralgia. — Ipecacuanha. 
The chill is preceded by yawning, stretching, and the collection 
of saliva in the mouth, and accompanied with persistent 
nausea, vomiting, diarrhoea. There is rarely thirst during the 
cold stage ; decided aggravation from the application of exter- 
nal heat. The hot stage lasts a long time, with much thirst 
and gastric irritability throughout. Oppressed breathing; 
dry, hacking cough ; unequal distribution of heat ; head and 
face hot; one hand hot, the other cold. The sweating is not 
profuse ; sour sweat ; turbid urine ; feeling as though very ill, dur- 
ing the sweating. The gastric symptoms continue all through 
the paroxysm and the intermission; thirst is rarely great 
during any stage ; the stages often are not clear-cut ; there is 
much faintness and "goneness" at the stomach. Is said to be 
especially useful after the abuse of Arsenic and Quinine. — 
Quinine. The paroxysms are regular and distinct. The cold 
stage is accompanied with painful tenderness in the dorsal 
region, which lasts into the hot stage, with much tenderness on 
pressure ; the temperature ranges high ; there is pungent heat 
of the surface, great thirst, highly flushed face, possibly delirium. 
Sweating breaks out gradually and is copious. There is con- 
tinued pain in the lower spine. Swelling of the spleen, with 
soreness on pressure in the spleen and liver. "Brickdust" or 
fatty sediment iu the urine. The tongue is clean. Ringing in 
the ears. Dizziness. The head feels large. — China. "After the 
first paroxysm, the apyrexia "will show debility hardly in ac- 
cordance vrith the severity of the attack ; not full relief of the 
cephalic congestion, as manifested by noises in the ears, head- 
ache with an increased feeling of fulness in the head ; sense of 
constriction from ear to ear over vertex ; appetite easily satis- 
fied ; and, usually, swollen liver. During the chill, which may 
not recur at the same hour each day, and is usually short, 
though it may be violent, there is not much thirst, but the cere- 
bral pressure is marked by nervous sensitiveness and irrita- 
bility; the hands and feet are very cold; the respiration is 
hurried, though the lungs do not show much congestion. The 
hot stage is general and long, but there is not much thirst ; the 



68 SPECIFIC INFECTIOUS DISEASES. 

hands and feet become warm ; the veins swell ; the patient, still 
sensitive, is intolerant of covering, and the general condition is 
one of extreme nervous excitement, the face being red and 
flushed, and the brain still pressed. Profuse, weakening sweat 
follows, the thirst now making its appearance to supply the 
loss; tenderness of the spleen and sleepiness" (E. U. Jones). — 
Arsenicum album. The stages and the intermission are rarely 
well defined. The chill is not severe, though usually pro- 
nounced ; internal shivering and coldness, with external heat. 
Drinks little at a time, with pain and distress in the stomach 
and vomiting after drinking ; abdomen bloated ; anxiety, rest- 
lessness, irritability, pronounced prostration. The hot stage 
may be clear-cut or consist of alternate spells of heat and shiver- 
ing, or of both at the same time. The constitutional symptoms 
are severe ; there is intense restlessness and anxiety' ; severe 
headache, with vertigo ; burning in the stomach ; tension and 
pressure in the left hypochondrium ; characteristic thirst ; dry, 
red tongue ; anxious, oppressed breathing ; palpitation of the 
heart. The sweating appears gradually, possibly not at all ; it 
may be copious and protracted ; but it does not materially 
relieve the patient. During the ap} r rexia the patient presents 
pallor and sunken appearance of the face ; great prostration, 
irritability, despondency- ; characteristic gastric symptoms, with 
loss or perversion of taste, distress after eating, fetid, watery 
diarrhoea, sometimes dark ; scanty, turbid urine ; pale, dry, 
cold skin ; at times cold, clammy perspiration, oedema of the 
feet, and all the way through a sensation of great weakness. 
" Tertian fevers, such as are caught on the seashore." — Natrum 
muriaticum. "The general symptoms of the patient show 
cachexia. He is dejected, apprehensive of the future ; easily 
chilled, and takes cold easily ; comparatively emaciated ; of a 
sallow complexion ; feeble heart-action, and consequently easily 
excited and sometimes intermittent pulse. The apyrexia is 
characterized by debility,, is imperfect ; aching in the liver ; ten- 
derness of the spleen and increase of turbid urine, with deposits 
of urates; sallowness of the complexion. It may last from 
twelve to thirty-six hours, but the attack is usually quotidian. 
During the pyrexia there is almost constant headache ; the 
chilliness commences near noon (11 o'clock, as has been con- 
stantly verified by my own experience), and is not entirely ab- 



REMITTENT FEVER. 69 

sent through the succeeding stages, as is the thirst, which com- 
mences with the chill ; vomiting, with bitter taste in the mouth ; 
even cold water is quickly ejected. The hot stage is moderate, 
and is not always free from a suspicion of chilliness ; the head- 
ache, which seems to have connection with the disorders of the 
nutritive system, increases ; the oscillations of sensational tem- 
perature give greater palpitation of the heart ; ' blisters form 
on the lips like pearls.' The sweat varies in its force and dura- 
tion, but generally relieves the headache and bone-pains." (E. 
U.Jones.) 

REMITTENT FEVER. 

A form of malarial fever which is characterized by continuous 
elevation of the temperature above normal, with marked re- 
missions and usually symptoms of gastro-intestinal irritation. 

The structural changes noted, post mortem, are largely those 
of severe intermittent fever. The spleen, at first, becomes 
hyperaemic and swollen, then permanently enlarged, remaining 
soft ; the liver is hyperaemic, and in cases of long standing may 
become atrophic. Extensive pigmentation, also seen in other 
severe forms of malarial infection, constitutes one of the most 
striking changes peculiar to remittent fever. The organs in- 
volved have a dark appearance, in protracted cases resembling 
bronze; sometimes the color is grayish or bluish-black. This 
pigmentation has been seen in the spleen, liver, brain and 
marrow of long bones ; other highly vascular organs, as the 
kidneys, pancreas, thyroid gland, and even the skin, may be 
found more or less pigmented. 

Clinical History. — In some cases a prodromal stage is noted, 
consisting of malaise, headache, shivering, possibly vaguely 
defined paroxysms. More often the onset of the disease is 
marked by a chill, followed by high fever. In many cases the 
gastric symptoms are pronounced, the patient suffering early 
from furred tongue, prolonged nausea and vomiting, epigastric 
tenderness, often watery diarrhoea, and, a .state of intense 
''biliousness," at times with copious vomiting of bile; jaundice 
also may be present. 

During the fever which follows the chill, the temperature rises 
to 102° to 106° F.; the pulse is full, bounding, in exceptional 
cases dicrotic ; the face flushes ; there may be considerable in- 



70 SPECIFIC INFECTIOUS DISEASES. 

volvement of the nervous system, even to delirium. The fever 
here continues much longer than does the hot stage of the 
intermittent, and ten, twelve, even twenty-four hours, may 
elapse before it passes off. A slight sweat usually follows, with 
much relief, marking the beginning of the remission, which com- 
monly takes place at midnight or during the hours of early 
morning. The temperature, however, remains from 2 to 4 
degrees above normal until the appearance of the next 
paroxysm, when it again rises. 

The paroxysms recur much after the manner of the intermit- 
tent fever, corresponding to its types. In the average case 
they become lighter after the first week, and subside by gradu- 
ally decreasing in severity or by assuming a distinctly intermit- 
tent type, or by crisis. The average case runs from two to 
three weeks ; recovery sometimes takes place in a week. 

Again, the case may be greatly protracted by the develop- 
ment of symptoms of great depression of the nervous system, 
giving rise to a state which resembles typhoid fever ; this re- 
semblance often is great, and the haggard, worn, anxious look, 
pallor of the face, dryness of the tongue, muttering delirium, 
enlargement and tenderness of the spleen which are present in 
both these diseases, both preferabh' appearing in the same time 
of the year — the months of autumn — may render a differential 
diagnosis very difficult. In fact, bacteriological tests may alone 
be able to settle the diagnosis. 

The prognosis is more serious than that of intermittent fever, 
but in uncomplicated cases it is favorable. Anaemia, dropsy, 
or permanent enlargement of the spleen frequently follow. 

Treatment. — The most important remedies are : Baptisia, 
Bryonia, Gelsemium, Rhus, Arsenic, Mercurius, Iris, Podo- 
phyllum, Leptandra, and Nux vomica. The remedies con- 
sidered under Intermittent Fever and under Typhoid Fever may 
also be consulted. 

Baptisia is by all means the remedy which most frequently 
cuts short the course of this disease. It has dull, frontal head- 
ache, sometimes oppressive and stupefying; gastric and ab- 
dominal uneasiness and pain, involving also the liver; rumb- 
ling in the bowels ; thick, yellow coating of the tongue ; bad, 
flat taste in the mouth ; fetor of breath ; diarrhoea of mushy 
stools ; general muscular soreness, bruised sensation all over. 



REMITTENT FEYER. 71 

Face looks dark, besotted ; there is mental confusion, a half- 
dazed state, with low muttering delirium. — Bryonia ranks 
next. Under it the gastric irritation is greater ; there is more 
constant, aggressive vomiting, frequently of a bilious charac- 
ter. The chill is accompanied and followed by violent throb- 
bing, bursting frontal or occipital headache, sharp stitches in 
the spleen, bronchitis, with great soreness when coughing, and 
great thirst during the fever, which has burning, intense in- 
ternal heat. Delirium during the night. Dislikes to be touched 
or moved. — Gelsemium is useful in the early stage (see "Inter- 
mittent "). It has made a good record in the treatment of all 
the malarial fevers of children. The muscular weakness is espe- 
cially pronounced, with great restlessness ; duskiness of the 
face; dizziness; indifference. — Rhus and Arsenic come into play 
when the symptoms resemble those of typhoid fever. Rhus has 
a red triangle at the tip of the tongue, great weakness, with 
trembling of the hands, dry brown tongue ; pain in the back 
and legs. — Arsenicum : profound adynamia ; the remissions are 
well-marked ; characteristic thirst ; much distension and heat 
of the abdomen, with rumbling in the bowels and dark, fetid 
diarrhoea; diarrhoea of putrid, undigested stools. — Mercurius 
frequently covers the hepatic symptoms ; tenderness and sore- 
ness in the liver; jaundice; dark and offensive urine. — Iris has 
much gastro-intestinal irritation, with violent and exhausting 
vomiting of copious and intensely sour water mixed with 
yellow, green bile. — Podophyllum acts especially well in chil- 
dren, when there is tendency to bilious diarrhoea, loss of appe- 
tite, belching of sour, hot flatus; everything taken into the 
stomach, drink or food, turns sour. — Leptandra and Nux yom. 
prove serviceable when their well-known indications are pres- 
ent. — Eupatorium perfol. (see "Intermittent") in doses of 
from five to ten drops of the tincture, every one to two hours, 
is advised by Hale. 

Chininum ars. and Quinine. — "There is a tendency in a re- 
mittent, ending on the seventh or fourteenth day, to recur in 
seven or fourteen days after. Here quinine is indicated ; two 
grains three times a day, or the arsenite of quinine, a grain of 
the first decimal three times a day, until the critical day has 
passed" (E. M. Hale). 



(2 SPECIFIC INFECTIOUS DISEASES. 

PERXICIOIS MALARIAL FEVER. 

This form, as indicated by its name, is always serious. It is 
found in persons who from previous attacks of malarial fever 
or some other disease are much exhausted or into whose sys- 
tem an unusually large amount of the malarial poison has been 
received. The " pernicious " quality of the fever is said never to 
show itself in a first attack of malarial infection, but in the 
second or third attack. It is of rare occurrence in temperate 
climates, but comparatively frequent in the South. 

The various types of pernicious malaria depend upon the 
prominence of special symptoms ; those most frequently recog- 
nized are the bilious, algid, asthenic, comatose and haemor- 
rhagic. 

The bilious form. Symptoms of "biliousness," as coated 
tongue, foul breath, loss of appetite and constipation, may pre- 
cede the attack ; muscular soreness and pain are often present. 
General irritability of the nervous system, peevishness, and 
frontal headache may be noted, especially among persons who 
have had previous attacks. The muscular pain is hardest in 
the loins and knees, is accompanied with much soreness, and 
may be very great ; in severe cases neuralgia of the large nerves 
(as the sciatic) and cramps in the calves of the legs may occur. 
If the first symptom is a chill, it may be very severe, and violent 
vomiting will probably be present. During the fever the pulse 
is rapid, the heart's action irritable, the face deeply congested, 
and the eyes staring, glistening. The temperature runs high, 
up to 105°, or higher. Vomiting is persistent, copious, bilious. 
There is much tenderness in the epigastric, hepatic and splenic 
region, with great loss of flesh and strength. In the rapid 
progress of this form marked prostration and anaemia develop ; 
the bowels, from loss of strength of the intestinal muscular 
fibre, become stubbornly constipated ; pronounced jaundice in 
some cases develops early and rapidly; the urine is dark, of 
high specific gravity, and contains an excess of urates and phos- 
phates, in severe cases bile pigment and blood. 

Occasionally, diarrhoea is noted, with dysenteric or choleraic 
stools. The hot stage is by all means the most pronounced ; 
the cold stage and that of sweating may be very light or 
absent. 



PERNICIOUS MALARIAL FEVER. 73 

The algid form closely resembles cholera, and is very often 
fatal. There is active vomiting and purging; intense thirst, 
feeble, small pulse ; hurried breathing ; coldness of the body ; 
huskiness of voice ; cramps ; scanty or suppressed urine ; utter 
prostration; collapse. External coldness of the body may exist 
with high internal temperature. Death usually occurs from 
asthenia. 

The asthenic or adynamic form is marked by early and pro- 
found prostration of the nervous system, with feeble and irregu- 
lar action of the heart and pulse ; the sweating is very copious 
and exhausting ; here, also, death occurs from asthenia. 

The comatose form is a disease of tropical countries ; when 
seen in temperate climates it is usually found in localities 
-where the malarial miasma is concentrated and in persons who, 
residing in such localities, have neglected proper care and treat- 
ment of repeatedly occurring attacks of malarial fever. The 
clinical history is one of early profound coma, with death in 
collapse, or of violent delirium with evidence of intense cerebral 
congestion. In the former, death is due to general toxaemia; 
in the latter, cerebral hyperaemia and oedema are found post 
mortem. 

The hsemorrhagic (hasmaturic) form, also, is very dangerous.' 
It begins with prolonged chill and rigors, followed by a rapidly 
rising temperature; there is restlessness and anxiety on part 
of the patient ; scantiness of urine, which soon is loaded with 
blood-discs, bile pigments, albumin, and granular and blood 
casts. Haemorrhage from the mucous membrane (nose, mouth, 
stomach, vagina, rectum) appears, with, often, intense haema- 
togenous jaundice, the skin in some cases assuming a bronze 
color. The constitutional symptoms, as vomiting and head- 
ache, high fever, dry, hot skin, etc., continue. If the case is 
severe, delirium, coma, Cheyne-Stokes respiration, and death 
supervene. 

So long as the mind remains clear, the outlook continues 
favorable; the development of delirium or coma renders the 
case critical. The haemorrhages, according to Thompson, 
"usually bear a direct relation to the intensity of the chill, 
which favors internal congestion." Death is due to toxaemia 
or asthenia. 

Diagnosis. — Pernicious malarial fever resembles typhoid 



74 SPECIFIC INFECTIOUS DISEASES. 

fever, yellow fever, cholera; also, ulcerative endocarditis and 
P3'asmia, urcemia and meningitis. Typhoid fever has rose- 
colored rash, epistaxis, tympanitis, characteristic (pea-soup) 
stools, relatively slow onset, characteristic temperature curve, 
more continuously sustained fever, and characteristic tongue ; 
the nervous symptoms (as subsultus, ataxic symptoms, etc.), 
are also more pronounced. In malarial fever the tongue is 
larger, flabby, with thicker, heavier coating ; greater intensity 
of the gastric and bilious symptoms, with persistent jaundice. 
"Aggressiveness" of the symptoms. During the paroxysm 
"the face is more flushed, the eyes are congested, and the ex- 
pression is more animated than in typhoid fever." The history 
of previous paroxysms and of exposure to malarial influences 
must be taken into consideration. Yellow /ererismore quickly 
fatal, selects newcomers, has black vomit; jaundice appears 
later. Pernicious malarial fever is less quickly fatal, selects its 
victims among those who are old residents in malaria-infected 
districts, has no black vomit, has firmer pulse and higher tem- 
perature, and has jaundice earlier. Cholera is chiefly recog- 
nized by the presence of an epidemic, the clearness of its etio- 
logical factors, and the presence of specific micro-organisms. 
The occasional appearance of dysenteric, bloody stools in the 
algid form of pernicious malarial fever must be remembered. 
Ulcerative endocarditis may be approximately determined b} r 
physical examination of the heart and by establishing the 
existence of embolic infarctions ; in pyaemia a source of septic 
infection can usually be determined. These signs are absent in 
malarial poisoning. In uraemia and meningitis the coma 
appears later than in malarial fever ; it is preceded by photo- 
phobia and delirium, and there is a low temperature. 

Treatment. — The dominant school insist upon the immediate 
use, hypodermically, of fifteen-grain doses of one of the soluble 
Salts of Quinine, as the hydrochlorate, combined with one 
grain of Sodium chloride. Opium, Morphine, Atropine, 
Strychnine and heart stimulants are used as indicated, upon 
the basis that "everything depends upon tiding the patient 
over a present paroxysm and preventing the recurrence of the 
second, which is so apt to be fatal." Warburg's tincture 
of opium is used to control the vomiting and purging. 

The absolute necessit}- of using stimulants promptly and 



MALARIAL CACHEXIA. 75 

energetically by mouth, rectum, and hypodermically, according 
to the necessities of each case, is too evident to be discussed ; it 
includes the use of hot bottles to the feet, friction, etc. Feed- 
ing must be generous to the extent of the patient's ability to 
digest, at least as soon as improvement shows itself. Common- 
sense suggests the superior advantages of highly concentrated 
food in fluid form (egg-albumen in wine, preferably sherry; 
beef-juice, and special beef-preparations), given in small but in- 
creasing amounts every two hours. 

As to the use of quinine in the pernicious type of malarial 
fever, and the dose in which it should be given, great differences 
of opinion exist among writers of the homoeopathic school. 
In the main, there is an agreement that its chief value lies in 
its power to prevent a repetition of the paroxysm, and that 
doses of one to three grains, administered every few hours after 
the paroxysm has subsided, better answer the legitimate uses 
of the drug than do large doses ; the wisdom of using it hypo- 
dermically, if at all, is generally admitted. In the meantime, 
the remedy indicated by the symptoms of the individual case 
must accomplish the cure, and, in view of the extreme urgency 
of the case, may also be administered advantageously by the 
hypodermic syringe. 

The bilious type suggests Aconite, Bryonia, Crotalus, Podo- 
phyllum, Mercury. The algid form demands Camphora, 
Veratrumalbum, possibly Podophyllum. The a dynamic form 
requires Arsenic, China, Rhus. In the comatose form Opium 
is preeminently indicated. The symptoms of the hemorrhagic 
form are covered by Crotalus, Lachesis, Arsenic. Bella- 
donna, Curare, Phosphoric acid and others may be called 
for by existing symptoms. 

MALARIAL CACHEXIA CHRUNIC MALARIAL POI- 
SONING. 

The malarial cachexia is the result of gradual and effective 
saturation of the system with the malarial miasm. It is seen 
in persons who have had successive attacks of ague neglected 
or badly managed. To a certain extent an acute paroxysm, 
though not always without danger, may be looked upon as an 
explosion which affords protection against the more profound 
effects resulting from a persistent accumulation of the malarial 



76 SPECIFIC INFECTIOUS DISEASES. 

poison, slowly but surely undermining the constitution. It is 
for this reason that many of the victims of chronic malarial 
poisoning are found among those who have for a long time 
resided in malarial districts without having experienced any of 
the acute forms of the fever. 

Osier points out that the characteristics of the malarial 
cachexia are : anaemia and enlarged spleen ; these two condi- 
tions are always present. Additional minor symptoms occur 
which have led to the description of "types," such as bilious, 
gastric, etc.; these possess no clinical value. The appearance 
of a person suffering from chronic malarial poisoning is that of 
one thoroughly cachectic. The face is pale, of a dirty yellow, 
slightly bronzed color; the mental operations are performed 
slowly ; there is depression, emaciation, and loss of physical 
energy. The hands and feet are cold, the ankles often oedema- 
tous, and slight exertion results in breathlessness. Digestion 
is usually deranged. A "bilious" condition supervenes early; 
the tongue is large, flabby, thickly coated, with a whitish- 
yellow coating, and the edges bear the imprint of the teeth ; 
the taste and odor from the mouth are bad, offensive ; consti- 
pation or diarrhoea are present. The spleen is greatly enlarged, 
and it is in this form that the "ague-cake" may be dis- 
tinguished as low as the umbilicus, and even lower. There 
may be occasional shiverings and irregular paroxysms of fever ; 
neither are pronounced ; the temperature usually is low for 
days, but it may reach 102° or 103° F., and remain there for 
some time. In severe, cases cedema may become general. 

The diagnosis depends upon a history of long-continued ex- 
posure to malarious influences, the presence of amemia and 
splenic enlargement, and the demonstration of the "crescentic 
forms of the malarial germ and of flagellar in the blood." The 
duration of the disease is indefinite, and the prognosis reason- 
ably good, so far as eventual recovery is concerned. It is, how- 
ever, well to remember that the cachexia itself would prove a 
serious complication in case of a secondary disease, such as 
tuberculosis or d3 r sentery. 

Treatment — The general treatment must necessarily be tonic 
in character; good, wholesome food, careful attention to per- 
sonal hygiene, and promptness in controlling untoward symp- 
toms are of importance ; the condition of the bowels should 



MALARIAL CACHEXIA. 77 

receive special attention. Permanent removal to a non-malari- 
ous country is often imperatively demanded. 

The enlargement of the spleen may prove a source of especial 
anxiety to the patient. Proper constitutional treatment, if it 
cures the cachexia, will also cure this symptom ; however, if 
the patient worries, an ointment of mercuric biniodide or a 
belladonna plaster is unobjectionable. 

Arsenicum has become a routine prescription with physicians 
of all schools. It should only be used when the cachexia is -well 
established, with anaemia, great debility, difficulty of breath- 
ing, dropsical tendency, neuralgic affections, and the known 
keynotes of this remedy. "The tongue remains clear, and the 
pallor makes its appearance early." (Baehr.) — Chininum 
arsen. is preferred by many practitioners when the hot stage is 
marked, -with full strong pulse during the fever and with in- 
clination to uncover. The Iodide of arsenic has not been ex- 
tensively used in malarial cachexia; a careful study of its 
symptoms leaves the strong impression that it should be given 
extensive trial. — Natrum muriat., in the higher attenuations, 
is credited with many cures. Innutrition, great emaciation, 
prostration, sallowness and dryness of the skin, mental de- 
pression and tendency to intermittent pulse are among its 
characteristics. "Hard chill very often at 10 or 11 o'clock a. 
m., with great thirst, which continues through all stages. The 
heat is characterized by the most violent headache, relieved by 
perspiration. There soon appears an eruption of hydroa or 
fever blisters, which cover the upper and lower lips like pearls. 
During the apyrexia: sallow complexion, dry, white coated 
tongue ; bitter taste ; water tastes bad ; loss of appetite ; after 
eating, sour belching and vomiting ; pressure in the stomach ; 
swollen stomach; pain in the region of the kidneys; cutting 
pain in the urethra after micturition. ' ' ( Raue. ) — Ferrum covers 
many symptoms of the anaemic state, is recommended in en- 
largements of the liver and spleen, and has made a good clinical 
record. There is pallor of the face, which, however, flushes 
crimson from any slight start, pain, or emotion ; chilliness with 
thirst, vomiting of food, coldness of hands and feet; heat of the 
entire body, without thirst; exhausting sweat, with little, if 
any, relief of symptoms. Throughout the apyrexia there is 
much muscular debility and general exhaustion, somewhat 



78 SPECIFIC INFECTIOUS DISEASES. 

relieved from moving about ; vomiting of undigested food ; 
lienteria ; constipation ; oedema of hands and feet ; anaemic 
murmurs ; haemorrhagic diathesis. It is said to be useful after 
the abuse of quinine. — Lyco podium has marked digestive and 
bilious disturbances, with great intestinal flatulency, tender- 
ness to pressure in the region of the liver, despondenc}-, oppres- 
sion of the chest, sour vomiting, copious sour sweating, thirst. 
Fever from 4 to 8 o'clock p. m.— Lachesis. Symptoms of 
malarial poisoning recur every spring, especially after the indis- 
criminate use of quinine during the preceding autumn, as well 
as after the abuse of quinine generally. Chill without thirst, 
commencing in the small of the back, running up to the head, 
with chattering of teeth, soreness of chest ; wants to be held 
firmly to relieve the pain in the head and chest and to prevent 
shaking. Heat with thirst ; livid complexion ; oppression of 
chest ; loquacity ; internal sensation of heat while the feet are 
cold ; burning in the palms of the hands and soles of the feet, so 
he must uncover them. Profuse sweating affords relief. — Cal- 
carea carboxica. One of our best remedies. It is indicated by 
well-known characteristics, such as : affinity- for the scrofulous 
diathesis; large people of fair complexion, with glandular 
swellings, and chill with thirst ; heat and sweating without 
thirst ; external coldness and internal heat ; coldness of single 
parts ; great weakness, showing itself upon slight exertion, 
very marked when going upstairs. — Sulphur. History of sup- 
pressed rash or eruption, with heat on the top of the head and 
cold extremities ; ' ' red lips ; red tips of the tongue ; worse after 
eating ; sudden attacks of faintness, with hunger in the fore- 
noon ; costiveness, or else looseness of the bowels early in the 
morning, driving him out of bed ; hemorrhoidal complaint ; 
leucorrhoea ; cough when lying down in the evening ; feverish- 
ness through the night ; complete sleeplessness ; itching of the 
skin." — It is stated upon good authority that in the sulphur 
mines the malarial cachexia is unknown. Fumigations with 
sulphur are practiced in Africa by elephant hunters as posi- 
tively prophylactic. — M ercurius bixiodatus is recommended by 
E. U. Jones on account of its close relation to the glandular 
structure and its action upon the spleen and liver. " Constant 
chilliness, or chilliness with alternations of heat, followed by 
eas3' and copious perspiration, taking place generally during 
sleep." 



DENGUE-FEVER. 79 



DENGUE-FEVER.-" BREAK-BONE " FEVER. 

An acute infectious disease which occurs in tropical and sub- 
tropical countries, in a territory lying bet-ween 32° N. and 22° 
S. lat., usually appearing in the summer, characterized by fever, 
severe pains in the bones, joints and muscles, and frequently 
accompanied with an anomalous eruption of the skin. The 
contagiousness of the fever is still in doubt. It probably is 
carried by fomites ; it spreads rapidly along the lines of travel 
by ship or railroad, and as an epidemic invades large terri- 
tories. — No race, age or sex is exempt. 

Symptomatology. — The onset of the disease is sudden. A 
severe chill, or repeated shiverings along the spine, is followed 
by fever which, usually moderate, may rise rapidly, even reach- 
ing a temperature of 103° to 106° on the evening of the first 
or second day. There is boring, frontal headache, at times 
occipito-spinal, with intense, agonizing, boring, "breaking" 
pains in the bones, joints and muscles, with moist, yellow- 
coated tongue and high-colored, feverish urine, which may show- 
traces of albumin. — After three or four days the fever rapidly 
disappears, often by crisis, and an apyrexia sets in which con- 
tinues from two to four days and is characterized by weariness, 
soreness and stiffness all over the body and the presence of an 
anomalous eruption of the skin, -which may be macular, diffuse, 
lichen-like, vesicular or resembling urticaria. — At the expiration 
of this apyrexia a second paroxysm of fever sets in, with the 
same aching in bones and limbs which accompanied the initial 
paroxysm, but less severe ; in the course of two or three days 
the fever again falls, the temperature occasionally becoming 
subnormal, the eruption fades, desquamation takes place, and 
recovery sets in, commonly seven to nine days after the appear- 
ance of the first symptoms of the disease. 

The temperature in moderate cases does not rise above 103°, 
the pulse reaching 110 to 115 beats per minute ; exceptionally 
the former may reach 106° to 107°, the latter 120 to 130. In 
many cases the fever is remittent, -with evening exacerbations. 
Generally speaking, the pulse in dengue is soft; the tempera- 
ture, during the remissions, may drop to 95° or 96°. Falligant 
(Arndt's System) mentions a moist, cool condition of the skin, 



80 SPECIFIC INFECTIOUS DISEASES. 

with great sensitiveness to cold, and occasionally jaundice; he 
emphasizes the absence of thirst in dengue as characteristic of 
the disease. 

The pains are properly described as "bone-breaking;" they 
are very severe, often shifting, and not infrequently associated 
with cutaneous hyperesthesia. The joints are often swollen 
and red, resembling rheumatism. 

The gastro-intestinal symptoms may be sufficiently pro- 
nounced to constitute a distinct type of the disease, character- 
ized by severe vomiting and purging, with great general ex- 
haustion and, often, much weakness and irritability of the 
nervous system. Again, there may be a hemorrhagic tendency 
with moderate bleeding from the gums, nose, lungs, stomach, 
kidneys, bowels or uterus. Great restlessness and insomnia, 
only in part due to the general soreness of the body, are 
present in some cases. 

Enlargement of the lymphatics is frequent and may persist 
for weeks after the cessation of the fever. 

Convalescence is tedious ; it is characterized by remarkable 
and long-continued prostration of body and mind. Relapses 
are frequent. 

Complications are rare. The sequela? are unimportant, con- 
sisting of neuralgic pains, stubborn mental depression and suc- 
cessive crops of boils. The prognosis is favorable, death rarely 
occurring. 

Diagnosis. — The nature of the pain, especially when the 
articulations are severely affected, suggests rheumatism ; but 
the character and the course of the fever, the absence of acid 
sweating and of cardiac complications, as well as the 
anomalous eruption of dengue-fever, establish the diagnosis. 

"La Grippe" resembles dengue-fever in the rapidity with 
which it invades large territories and attacks entire popula- 
tions ; also in the suddenness of the onset, the great prostra- 
tion accompanying it, the frequency of relapse, severity of the 
pain, and the small mortal^ caused by it. But the grip differs 
in the entire absence of geographical restriction, the character 
of its fever, the absence of arthritic involvement, and chiefly in 
the seriousness of its complications and sequels. 

Treatment. — During the chill, artificial warmth, heavy bed- 
covering, hot foot-baths (mustard) and hot drink are recom- 



DIPHTHERIA. 81 

mended; during the fever, if there is thirst, cool drinks are 
allowable ; sponging in hot water-and-alcohol affords comfort 
if there is much sweating, and, with gentle rubbing, will relieve 
the soreness of the body. Light stimulants (hot brandy- 
toddy) will prove acceptable when there is much prostration. 

As to internal medication, Falligant recommends Aconite 
and Bryonia in the first stage ; Ipecacuanha to control vomit- 
ing and Arsenic for the diarrhoea. — Bryonia and Rhus when 
the fever is obstinate and when eruption is present. — Colocyn- 
this and Nux vomica for gastric disturbances. — Mercurius 
sol., China, Nux yom., for jaundice. — In hemorrhagic condi- 
tions Acid, sulphur., Arsenic, Secale, China. — Tinct. ferri. 
chlor. fort., in watery solution, every two or three hours, if a 
hemorrhagic diathesis is manifested. — Cantharides, Bella- 
donna and Arsenic in renal haemorrhage. 



DIPHTHERIA. 

Synonyms : Diphtheritis. — Angina Maligna. — Cynanche 
Contagiosa. 

An acute, infectious and contagious disease, characterized by 
the appearance of pseudo-membranous deposits upon the 
mucosa and upon the denuded skin ; the exudate contains the 
Klebs-Loeffler bacillus ; the disease is accompanied by constitu- 
tional symptoms of varying severity and, in a large number of 
cases, evidence of specific systemic infection. 

Etiology. — Diphtheria occurs endemically and epidemically. 
In the centres of population sporadic cases of the disease are 
almost constantly present ; under favorable conditions it may 
readily become epidemic. It is easily communicated from per- 
son to person by means of the pharyngeal excretion and the 
saliva of the sick ; it is doubtful if it is ever transmitted by the 
breath. Clothing, bedding, linen, toys and pet animals about 
the house may afford lodgment to the excretion, and thus be- 
come effective agents in spreading the malady. Often shreds of 
the membrane are violently thrown out in the act of coughing 
and brought into contact -with the mucous surface or denuded 
skin of physician or attendants, thus transmitting the infec- 
6 



82 SPECIFIC INFECTIOUS DISEASES. 

tion. A kiss upon the lips of a sick child may have the same 
disastrous effect. The specific poison is exceedingly tenacious. 
Sevestre states that in a Normandy village, twenty-three years 
after an epidemic of diphtheria, some of the bodies of those who 
had died of the disease were exhumed ; an epidemic at once 
broke out, first among those who had opened the graves, then 
extending to others. The radius of the infection is limited to a 
few feet. 

Season, soil, and occupation have little bearing upon the 
causation of diphtheria, although the disease is more frequent 
in the cold months of the year. Bad drainage and other insan- 
itary conditions can be considered only in so far as they may 
cause catarrhal conditions which, by lessening the integrity of 
the mucosa, render infection easier. Country villages possess- 
ing excellent drainage and good surroundings have in many 
cases furnished the battle ground for epidemics of frightful 
severity". Age is undoubtedly an important factor, diphtheria, 
though not confined to any period of life, being to all intents 
and purposes a disease of childhood. Children from three to 
five years of age furnish the larger portion of victims ; after 
fifteen years of age comparative safety is reached. But neither 
infancy nor .old age insure exemption. Important predisposing 
causes are chronic naso-pharyngeal catarrh, chronically en- 
larged tonsils, and generally unhealthy condition of the oral 
and pharyngeal mucosa. A diphtheritic tendency or predis- 
position on part of an individual or family is also recognized. 

The relation of the Klebs-Loeffler bacillus to diphtheria is 
very important. Pseudo-membranous deposits constitute an 
important objective symptom of the disease, but they are not 
limited to diphtheria ; they occur in other morbid states as 
well, and then resemble so closely the fibrinous exudate of diph- 
theria as to defy differentiation save by bacteriological means. 
The studies of Klebs and Loeffler (1883 and '84) first demon- 
strated the now universally recognized fact that the presence in 
the fibrinous exudate of the specific micro-organism named 
after them is limited to diphtheria. Other micro-organisms are 
found in the exudates of other diseases as well as in that of 
diphtheria, but this specific bacillus is peculiar to diphtheria. 
Inoculation of the mucous membrane with a pure culture of it 
promptly causes diphtheritic inflammation, followed by char- 



DIPHTHERIA. 83 

acteristic accompaniments and sequels, such as paralysis and 
typical organic disease. Injection of the toxalbumin obtained 
from it gives rise to violent systemic infection, accompanied by 
the specific constitutional manifestations observed in those sick 
with diphtheria. 

The Klebs-Loeffler bacillus is " about as long, but is twice as 
thick, as that of tuberculosis. It is always rounded at both 
ends, and is frequently knobbed, to present the appearance of 
dumb-bells, by which name it is frequently known. It is im- 
mobile, shows no spores, has its optimum temperature at body 
heat, and stains perfectly with alkaline methylene blue. It 
thrives in most of the culture soils, best in blood serum, and 
lives dessicated over one hundred days" (Whittaker). It is 
curved or spindle-shaped, and often is seen in groups. It is 
found in the outer and middle layer of the false membrane, but 
not in the deep fibrin layer, subjacent mucosa, blood, or internal 
organs, remaining always at the site of the local lesion. Its 
habitat outside of the human body is thought to be surface-soil 
rich in organic matter. Other bacteria, streptococci and 
staphylococci, are also found in the exudate, and work serious 
mischief, giving rise to secondary inflammation and suppura- 
tion of the serous surfaces and to the severe, frequently fatal, 
broncho-pneumonia of diphtheria. 

The local action is practically the primary effect of the specific 
poisonous organism. By contact it causes a necrosis of cells, 
especially of the superficial epithelium and leucocytes, soon 
followed by hyaline transformation — coagulation necrosis; thus 
the membrane or exudate is formed, composed of necrosed 
epithelium and leucocytes, pus, bacilli, fibrin, and at times red 
blood cells. More or less necrosis of the underlying mucous 
membrane and of the submucous tissues may exist, with hyper- 
emia and tumefaction of adjoining mucous structures. Event- 
ually the fibrinous exudation sloughs off, leaving a clean, 
smooth mucous surface ; if the process was severe, extensive 
necrosis of the deep layers is seen, and cicatricial tissue formed. 

The membrane itself at first appears as a thin, vaguely 
defined film. Developed, it is of grayish-white color, which 
grows darker, of a yellowish-brown as the exudate grows 
older ; it is elastic, firm, does not disintegrate when shaken in 
water, and swells in acetic acid. If it involves the superficial 



84 SPECIFIC INFECTIOUS DISEASES. 

tissue only, it is easih' removed, but is pretty sure to re-form 
shortly. If the deeper tissues are involved, it is less easily de- 
tached, and, stripped off, leaves a raw, bleeding surface. The 
edges are thin, and during the process of extension the outlines 
are lost. When resolution takes place, effusion of serum and 
immigration of leucocytes underneath loosens, first, the edges, 
which curl upon themselves ; with the aid of ulcerative pro- 
cesses complete separation results within a comparatively 
short time, the membrane sloughing off in flakes or in one 
piece. In some cases the membrane softens, and breaks down 
into an offensive dark, ichorous mass. 

The constitutional symptoms are the result of the absorption 
into the system of the ptomaines or toxines of the Klebs- 
Loeffler bacilli. Inoculation with attenuated cultures of diph- 
theritic virus is now practiced to insure immunity against 
diphtheria or, if too late, to rob the disease of its intensity. 

Symptomatology. — The period of incubation is indefinite; it 
varies from three to fourteen days, or even longer ; if the result 
of accident, as in case of physician or nurse being brought into 
contact with shreds^of membrane, it may not occupy more 
than from three to five days. 

Slight chilliness, moderate fever, malaise, general aching and 
soreness all over, especially in the back and extremities, eleva- 
tion of temperature, rarely beyond 103°, and rather rapid, but 
not full, pulse constitute the first symptoms of which the 
patient complains. In children, convulsions ma}' usher in the 
attack. Soon the throat feels uncomfortable and dry, with 
burning sense of constriction, tenderness, and some difficulty of 
swallowing. Examination reveals hyperemia, and later the 
formation of the pseudo-membrane, at first appearing on the 
tonsils, especially on the inner surface, as a white, fleecy film, 
looking much like mucus. There is more or less swelling of the 
parts and of the cervical glands. By the third day the exuda- 
tion covers the tonsils, fauces, and uvula; the soft parts are 
oedematous ; there is tenacious, yellowish secretion from the 
mucous glands, and fetor of breath. The membrane soon in- 
volves the posterior pharyngeal walls ; from gra3 T ish- white, it 
grows dark and dirty-looking, leaving a raw, bleeding surface 
if removed, new membrane rapidly forming. The constitu- 
tional symptoms are not necessarily severe; the tongue is 



DIPHTHERIA. 85 

badly coated, dirty yellowish; the pulse is rather rapid and 
light ; the temperature does not rise above 102° or 103° ; there 
is considerable difficulty of swallowing, but rarely enough to 
alarm patient or attendant. The urine may be normal ; more 
often it shows the presence of albumin. If the disease dips deep 
into the submucous tissues, which it may do even in moderately 
severe cases, the deeper connective tissue may be involved, and 
much soreness of individual glands, with great tenderness to 
pressure, is experienced. In very severe cases extensive tume- 
faction and complete obliteration of the outlines of the neck 
occurs. 

In the average light case, without extension of local affection 
or systemic invasion, the throat begins to improve at the 
end of the first week, glandular tenderness and enlargement dis- 
appear, the exudation is thrown off by the eighth or tenth day, 
and convalescence is established. Dangerous symptoms may 
arise from extension of the local disease or from systemic infec- 
tion. 

Extension of the local disease. — Extension may take place 
into the nares or into the larynx. It always greatly increases 
the gravity of the case. If into the nares, where it may occur 
primarily, there is copious, acrid, and fetid discharge, interfer- 
ence with respiration, and decidedly increased danger of sys- 
temic infection, owing to the abundance of lymphatics in the 
nasal mucous membrane. The process may involve the tear- 
ducts, conjunctiva, and antra, or by extension through the 
Eustachian tubes may give rise to otitis media and perforation 
of the tympanic membrane. t 

Still more to be dreaded is extension into the larynx, the so- 
called diphtheritic croup, symptomatically identical with mem- 
branous croup. The symptoms which indicate this extension 
— and it may occur when the pharynx is inconsiderably affected 
— are huskiness of voice, metallic, croupy cough, and rasping, 
stridulous breathing. The difficulty of breathing often in- 
creases with startling rapidity, so that the lower chest is vio- 
lently drawn in with each inspiratory effort, with depression of 
the supraclavicular and intercostal spaces. When the mem- 
brane extends into the trachea and bronchia, the condition be- 
comes exceedingly dangerous, the more so since it cannot 
always be recognized during life. Upon auscultation it is in 



86 SPECIFIC INFECTIOUS DISEASES. 

exceptional cases possible to recognize the existence of this 
calamitous complication. Occasionally relief is obtained by 
the expulsion, usually during a violent fit of coughing, of con- 
siderable masses of shreds of the membrane or of a complete 
cast of the affected tubes. Increasing cyanosis and death from 
asphyxia commonly terminate the case. 

. Systemic infection. — As a rule, this corresponds to the 
severity' of the disease, although extensive and severe local dis- 
ease may exist without pronounced systemic infection. Yet, 
when the exudation is widespread and disorganization of the 
false membrane occurs, with great fetor, there is always dan- 
ger of systemic poisoning. In such cases there will be enlarge- 
ment of the lymphatics, dirty pallor of the countenance, general 
and rapidly developing cachexia, rapid and feeble pulse, running 
up to 140, and more, beats per minute, and a dropping of the 
temperature below normal, in some cases preceded by a short 
rise. Gangrenous tendency may develop, with extensive slough- 
ing of the tissues of the neck. Again, evidence of systemic in- 
fection may be present from an early stage of the disease, and 
even from the very start the septic poison may overwhelm the 
vital forces. In such cases there will be early and extreme pros- 
tration, weak and rapid pulse, and a high temperature record, 
sustained for a few days, but gradually and with hourly 
increasing rapidity dropping to the subnormal. The throat 
symptoms may or may not be marked ; extension of the fibrin- 
ous exudation into the nares is rather common. 

In cases of septic infection the appearance of an eruption on 
the skin is not unusual. Observers have noted three forms : an 
eruption resembling that of scarlet fever, but disappearing 
more quickly and without desquamation ; an eruption not un- 
like that of purpura hemorrhagica, seen only in severe cases ; 
and blotches, dark red or dark pink, with sharply defined out- 
lines, disappearing under pressure, to return as quickly, with 
desquamation, often in successive crops ; the latter form war- 
rants a very serious prognosis. 

In practice this picture of the disease is modified by the mild- 
ness or prominence of special symptoms, the type of the epi- 
demic, and the constitutional peculiarities of the patient. It 
must be remembered that the mildness of the case does not in 
itself insure a favorable issue. There may be slight local 



DIPHTHERIA. 87 

trouble, -with little, if any, constitutional involvement, and yet, 
extension into the larynx or the appearance of a broncho- 
pneumonia may suddenly render the case threatening or hope- 
less. On the other hand, the local disease may be very extensive 
and unyielding, but the patient remain free from systemic in- 
fection and make a good recovery. Again, the use of the term 
"chronic type" may be justified by the tardiness of the resolu- 
tion of the local affection, the membrane forming and reform- 
ing, and delaying convalescence for many weeks. 

The exudation, instead of first invading the pharyngeal 
mucosa, may appear on the conjunctiva, external auditory 
meatus, vagina, vulva, or anus. Or if the skin be denuded, 
pseudo-membrane may form on the exposed part. Indeed, 
abraded or wounded surfaces during an epidemic of diphtheria 
are quite commonly the seat of persistent fibrinous exudation, 
and women recently delivered become at such times legitimate 
objects of especial care and apprehension. 

Complications and Sequelae. — Among the minor complica- 
tions likely to arise at any time, haemorrhage from the nose 
and throat, depending upon deep ulceration, is prominent The 
skin may be the seat of erythema, urticaria, or purpura. 
Parenchymatous changes in the heart, liver, kidneys and spleen 
occur here as in other forms of infectious disease. Capillary 
bronchitis, with broncho-pneumonia, are comparatively infre- 
quent, but exceedingly grave, complications. Gangrene, with 
severe and even fatal haemorrhage, may be caused by the 
gangrenous shreds of pseudo-membrane dropping into the 
bronchi. Renal complications are frequent, but usually need 
not cause anxiety unless large amounts of albumin are present 
in the urine, with epithelial and blood casts. Dropsy is rare. 
Endocarditis, pericarditis, pleuritis and arthritis occur excep- 
tionally. 

Of the sequels, paralysis is the most important and common. 
While comparatively rare in very young children, liability to it 
increases each year. It most frequently shows itself in the 
second or third week of convalescence, is undoubtedly due to 
the action of the toxines upon the peripheral nervous system, 
and has no relation to the mildness or severity of the case. In 
the greater number of cases it affects the palate, causing a 
peculiar nasal tone of the voice, difficulty of swallowing and of 



88 SPECIFIC INFECTIOUS DISEASES. 

manipulating food ; as in other forms of post-diphtheritic 
paralysis, there is weakness of the legs and loss of patellar 
reflex. — When the eye is affected, strabismus and difficulties of 
accommodation, with nearsightedness, result. — One or both 
limbs are frequently involved, giving rise to a sense of great 
weakness in the legs, with resulting awkwardness and unstead- 
iness of gait. — Loss of power of the heart-muscle constitutes 
one of the most serious complications. The heart beat may 
become abnormally slow, from 30 to 35 beats per minute, or 
its rate may be increased to 160, or more, per minute; or the 
two extremes may alternate in the same patient. Heart-failure 
and fatal syncope, at the height of the disease, is not unusual, 
and sudden cases of death from this cause may occur during 
convalescence. Liability to this accident strongly emphasizes 
the absolute necessity of cautioning a patient against making 
any sudden or violent exertion. 

Post-diphtheritic parah'sis appears without prodromata, is 
characterized by impairment or loss of the knee-jerk, is rarely 
complete, and usually warrants a favorable prognosis. 
Struempell states that after diphtheria the patellar reflex is 
often lost for weeks and months, even in persons who have 
entirely escaped the nervous disorders. 

Diagnosis. — Diphtheria is differentiated from follicular tonsil- 
litis by the more definite character of the exudation, the more 
clearby defined area of mucous membrane involved, the existing 
lymphadenitis and tumefaction of the parts, albuminous urine, 
greater prostration, and the epidemic character of the disease. 
Epidemic tonsillitis, or quinsy, at times resembles diphtheria, 
but the throat symptoms are more acute than those of diph- 
theria, there is more pain and distress, and greater swelling and 
dysphagia ; the oedema of the soft parts is more pronounced in 
tonsillitis ; there is absence of pseudo-membrane. The course 
of the disease is more rapid, the actual suffering greater, there 
is no interference with the patellar reflex, and the prognosis is 
good. The differentiation between diphtheria and membranous 
croup is difficult. The appearance of the membrane in both is 
the same, save that the diphtheritic bacillus is not present in 
croup. In croup, however, the invasion is' much more sudden 
and the symptoms are sufficiently severe in the very beginning 
to create anxiety, while in diphtheria a more protracted and 



DIPHTHERIA. 89 

well-defined initiatory stage is noted, without, often, violent 
symptoms. Membranous laryngitis is to all intents and pur- 
poses a local disease, without marked constitutional concomi- 
tants ; diphtheria, while localized, has constitutional symptoms 
of marked severity. In membranous croup the larynx consti- 
tutes the point of invasion ; in diphtheria it is the pharynx, 
and the larynx is involved later by extension ; if necrosis occurs, 
it is superficial in membranous croup, but involves the deep 
structures in diphtheria ; membranous croup is neither epidemic 
nor contagious ; diphtheria is both ; the former is a disease of 
infancy, the latter may occur in adults. The pseudo-mem- 
branous sore throat of scarlatina appears later than that of 
diphtheria ; it occurs only in exceptionally severe cases of the 
fever, while in diphtheria it is always present ; in scarlet fever 
the entire upper respiratory tract is involved, in diphtheria first 
the pharynx, then the larynx ; in scarlet fever glandular affec- 
tions, with suppuration of the ear and induration of the 
glandular connective tissue, are frequent; in diphtheria sup- 
puration is rare, and the glandular connective tissue becomes 
cedematous ; in scarlatina paralysis is rare, and nephritis with 
dropsy is frequent; in diphtheria paralysis is common, and 
nephritis is rare and hardly ever associated with anasarca. 
Other pathognomonic symptoms, as the " strawberry tongue " 
of scarlatina and the loss of knee-jerk in diphtheria will still 
further clear the diagnosis. 

Prognosis. — The prognosis of diphtheria must be guarded, 
for it presents a mortality rate which runs very high. Au- 
thorities of the dominant school place it at 40 to 76 per cent.; 
there is no question but that under homoeopathic medication 
it is smaller. Yet, it is justly considered one of the most 
serious diseases with which we have to deal. Over fifty per 
cent, of all the deaths occur in children of less than five years 
of age, and about seventy-five per cent, in children of less than 
ten years old. In hospital practice the disease has proved 
especially intractable. 

It must be remembered that the severity of the local pharyn- 
geal lesion does not constitute the great source of danger ; it is 
the extension into "the larynx or nares and the systemic infec- 
tion -which betokens coming trouble. When the diphtheria- 
poison pervades the system, heart failure, fatal syncope, and 



90 SPECIFIC INFECTIOUS DISEASES. 

similar grave complications, may at any time, terminate life, 
even though the local disease appear insignificant. 

Profound adynamia, extension of the membrane into nose or 
larynx, extensive suppuration, gangrene, pronounced urasmia, 
broncho-pneumonia, during the active progress of the disease or 
during convalescence, are complications which at all times 
warrant a guarded prognosis. 

Treatment. — Prophylaxis. — Here, as in all violent infectious 
diseases, the intelligence and conscientiousness of the health 
officers is of supreme importance. To them must fall the re- 
sponsibility of detecting sporadic cases, and of keeping in check 
and eventually stamping out of existence epidemics of diph- 
theria, as of small-pox. Hearty and honest cooperation on 
part of the medical profession will eventually convince the 
public of the necessity of giving full support to all such efforts. 
The careful inspection of all places of a public character, espe- 
cially of schools and churches, of public conveyances, of sewers, 
outhouses of all kind, etc., is an absolute necessity-. Isolation 
and disinfection should be rigidly enforced, in spite of e very- 
effort to circumvent such efforts. Individual dwelling houses 
and their inmates are not exempt from the enforcement of 
these precautionary measures. 

If a case of diphtheria occurs in a family, such children as 
have not been exposed should be removed, if possible; if not 
convenient or too late, they must be quarantined and carefully 
watched. Since a bad condition of the mucous membrane con- 
stitutes a predisposing cause of diphtheria, it is well, even at 
this late day, to correct, so far as possible, existing catarrhal 
troubles, and to take especial pains to heal or protect fissures, 
abrasions and wounds. Pregnant or lying-in women need to 
be carefully- guarded, since the uterus or vulva, after confine- 
ment, are readily infected. The nipples of nursing women, if 
fissured or sore, are to be watched, and the mouth of the nurs- 
ling is to be kept scrupulously- clean to prevent stomatitis or 
thrush. School-children should not be allowed to re-enter school 
until all danger has passed of their acting as disease-carriers. 
A certificate from the health officer or medical attendant should 
be exacted before re-admission to school is granted, and this cer- 
tificate should not be furnished until the child is entirely well 
and all acrid nasal or other discharges have ceased. The 



DIPHTHERIA. 91 

rooms used for the sick and clothing worn by them must be 
duly disinfected. Funerals should be held speedily and be pri- 
vate. 

Care of the patient. — The patient should at once be isolated ; 
if not sure of the diagnosis, it is best to err on the side of safety. 
This isolation should be absolute ; the attendants also should 
be quarantined. A large, airy, well-ventilated top-room, kept 
at a temperature of 65° or 70°, will answer best. All furniture 
not absolutely needed should be removed. Dishes and other 
needed utensils must be kept in the sick-room or, better, in an 
adjoining room set apart for the purpose, since by being carried 
about the house they will almost surely become carriers of the 
infection. Discharges from the mouth and nose must be re- 
ceived on cloths, which are burnt at once ; excreta are received 
in glazed earthenware which contains sublimate solution 
(1:5000). No "pets" are tolerated in the room; pains must 
even be taken to kill flies which readily find their way into the 
sickroom and from there to other parts of the house. Food, 
especially milk, must not be allowed to stand in the sickroom. 
Brushes used in the local treatment are to be kept in sublimate 
solution ; swabs are burnt as soon as used. The child must re- 
main in a recumbent position, and no unnecessary exertion is 
to be allowed. So important is this rule, on account of unex- 
pected heart failure and syncope, that it is well to use a feeding 
cup, and to have an attendant within easy reach to assist the 
patient when he desires to rise or offers to exert himself. Only 
one patient is allowed in the same room. Disinfection may be 
maintained by hanging outside the door sheets wet with some 
disinfectant solution and by medicated vapor sustained by 
means of a small stove. The following is recommended for this 
purpose : 

#. 01. eucalypt., 

Acid carbol., aa 3 vi. 

Spts. terebinth., § vi. M. 

Sig. — One tablespoonful in a pint of water. 

The attendants, for their own protection, must make free use 
of disinfectants, and after handling the patient, especially 
about the mouth or nares, should wash their hands in corro- 
sive sublimate solution (1:10000). They must take particular 



92 SPECIFIC INFECTIOUS DISEASES. 

care to avoid having detached membrane come in contact with 
their face, especially the eyes or hands, when seeing to the needs 
of the child during paroxysms of gagging or coughing. 

Diet. — The feeding of the patient is very important. Solids 
are usually out of the question ; the liquids employed should 
represent concentrated and easily digested nourishment. Milk, 
cream, kourrvyss, ice cream, broths, meat-jellies, chicken broth 
or jelly, raw egg beaten up in milk, will for a long time main- 
tain the strength of the patient. Feeding per rectum may be- 
come a necessity. Proper feeding is so important an item that 
the physician will do well to give it his particular attention, to 
direct what is to be fed and how often nourishment is to be 
given, and to satisfy himself at every visit that his orders are 
obeyed to the letter. 

Stimulants are well borne, as a rule ; in many cases they are 
a necessity. Of these, champagne is the most grateful. Even 
to an infant a teaspoonful of champagne every two to four 
hours may be given to advantage. Next in value rank good 
old whiskey and brandy. Small doses, frequently repeated, are 
more satisfactory than large doses at longer intervals. 

Local Treatment. — It is generally admitted that local meas- 
ures, judiciously applied, are beneficial. Indeed, if the early 
destruction of the bacillus is sufficient to prevent systemic in- 
fection, every effort should be made to bring about this result. 
Aside from this, local treatment serves to dissolve the mem- 
brane, to allay irritation and, perhaps most important of all, 
to preserve cleanliness. 

In the employment of local treatment it is well to observe the 
following rules: feed the patient before, not after, treatment. 
Save to the utmost the strength of the patient ; to that end 
avoid being "fussy" and do not allow unnecessary exertion on 
part of the sick. Under no circumstances use force in attempt- 
ing the removal of the pseudo-membrane. Be careful to re- 
move every thread loosened ; if not removed, it may be swal- 
lowed or may enter the larynx and form a new focus of 
infection. Guard against the sputtering and coughing of the 
patient, lest 3 r ou become infected from shreds of membrane 
violently expelled by the effort. The applications used must 
be warm and consistently mild. 

Pharyngeal Diphtheria. — My own experience in the use of 



DIPHTHERIA. 93 

local applications for the purpose of dissolving the diphtheritic 
membrane has not been satisfactory. I am strongly of the 
belief that their use often does much more harm than good, 
especially if the necessary manipulations are not performed 
with the utmost gentleness. Many able practitioners, how- 
ever, stoutly maintain their usefulness. Bichloride of mercury 
is a favorite application ; the following is a standard formula : 

J*. Hydrarg. chlor. corrosiv., 1 part. 

Acid, tartar., 5 parts. 

Aqua, 10,000 parts. 

Wipe off the diphtheritic membrane with a wad of cotton ; 
thoroughly swab the bleeding surface with the solution ; three 
to five wads may be required for each side of the throat to 
remove the entire membrane ; repeat every six to twelve hours. 
When the tonsils are clear, use a large -wad or swab over the 
entire pharynx. 

Whittaker prefers the subsulphate of iron. He applies it by 
means of a cotton- wrapped sound, the end of which is immersed 
in the undiluted solution and pressed on withdrawal against 
the neck of the bottle, so that the fluid may not drop into the 
larynx ; the false membrane is touched or the surface painted 
quickly. He uses one application a day in the ordinary case ; 
two in bad cases. Spraying by means of a hand atomizer, 
with hard rubber nozzle, and capable of throwing a continuous 
and fine spray, is frequently advisable. 

Peroxide of hydrogen, in ten or fifteen vol. solution, pure or 
diluted with equal amount of water, and used every four to six 
hours, has given satisfaction. In children less than three years 
old not more than one tablespoonful of the undiluted substance 
should be used ; in those from three to ten years of age, twice 
this amount may be employed safely. The occasional or even 
alternate use of a spray of corrosive sublimate (1:5000) has 
been recommended. 

Insufflation of sulphur, by means of a tube of small calibre, 
applying it directly to the membrane, constitutes a milder, but 
often very effective, local measure. Cameron, before using the 
sulphur, gargles the throat with : 

fy. Potassii chlorate, 5 '■ 

Glycerini, 3 "• 

Aquae, 5 viii. M. 



94- SPECIFIC INFECTIOUS DISEASES. 

Goodno claims good success with a trituration of potass, 
permanganate, one grain to the ounce, applied by insufflation 
every few hours to throat or nares. 

Nasal form. — Cleanliness of the nares is of great importance, 
on account of the tendency toward extension into those parts 
and the difficulty of treating them locally. Children whose 
pharyngeal vault is filled with adenoid growths are especially 
liable to extension of the exudation into the nares. All local 
treatment must be applied with gentleness, else more harm 
than good will result. 

The use of chlorate of potassium and glycerine, or borax and 
glycerine, with the addition of a little carbolic acid, by means 
of the douche, spray or syringe, is frequently advantageous. 
Cameron likes the peroxide of Irydrogen, but urges that the 
nozzle of the atomizer be kept exactly in the middle line of the 
nares, since otherwise it will impinge upon the septum or in- 
ferior turbinated bone and cause epistaxis. 

A small syringe, with small piece of rubber tubing over the 
nozzle, insures gentleness and effectiveness of application. The 
stream must be applied horizontally and gently, the head held 
well forward, and the child urged to breathe through the 
mouth. Should pain in the ear follow the operation, the medi- 
cine dropper must take the place of the syringe. For purposes 
of cleanliness alone, use a saturated solution of boric acid or a 
solution of 1 to 10 minims of carbolic acid to one ounce of lime 
water. 

Laryngeal form. — Keep the air in the room moist by vapor or 
steam inhalations, which may be medicated. Any good steam 
atomizer will answer the purpose for adults. In the case of 
children it is usually necessan^ to place over their bed or couch 
a tent, left open on one side, for purposes of ventilation. The 
steam is introduced by means of a common kettle, left outside 
the tent; the nozzle is placed within the tent, at a sufficient dis- 
tance from the patient to prevent the possibility^ of his being 
scalded or burnt. A tablespoonful of oil of turpentine may be 
added to the water, or oil of eucalyptus, not more than 40 to 
60 drops ever}' three hours, or carbolic acid ; the latter must 
not be used too persistently, lest it might affect the kidneys. 

If the obstruction increases, and breathing becomes more and 
more embarrassed, relief must be given by intubation or trach- 



DIPHTHERIA. 95 

eotomy ; in either case such relief must not be postponed until 
too late. Stern (Internat. Med. Congress, 1887) advises intu- 
bation in preference to tracheotomy when the patient is less 
than three and a-half years old ; in all adults ; among poor 
people, because they cannot afford the expense of the skilled 
nursing necessary after the tracheotomy ; in cases were skilled 
assistance cannot be had. When there is reason to think that 
the trachea is filled with membrane, intubation is never indi- 
cated. Tracheotomy is advised in children over five years of 
age, and, compared with intubation, is preferable in patients 
between three and a-half and five years old. 

Cutaneous Diphtheria is rare. The membrane must be re- 
moved as far as possible, followed by irrigation with sub- 
limate solution (1:2000), dusting with iodoform, aristol, boro- 
aristol, or similar agents, finally dressing with sublimate gauze 
and proper bandage. 

Post-diphtheritic paralysis is usually benefited by the use of 
the electric current. The sittings must not be too protracted 
nor the current used too strong. This applies with particular 
force when operating upon the muscles of the eye ; here not 
more than four to six milliamperes should be used, and the sit- 
ting should not be longer at first than two minutes, to be 
gradually extended to five minutes. Place the positive pole on 
the temple, the negative pole on the lid of the effected eye. 
Eserine solution, two grains to one ounce, instilled into the 
eye, is useful in mydriasis. 

Therapeutics.— In the early stage: Belladonna, Mercurius 
biniodat., Phytolacca. 

Belladonna : Bright redness of the fauces ; dryness of the 
throat ; difficulty of swallowing, especially liquids ; high, active 
fever; glowing heat of the skin; cerebral congestion; slight 
exudation. — Mercur. biniodat.: Exudation not very extensive, 
white, thick, creamy, easily detached; thick, ropy saliva; swal- 
lowing of food and drink very painful from the start ; feeling of 
a lump in the throat, with constant hawking and spitting; 
loss of appetite. — Phytolacca: Redness and swelling of the soft 
palate, tonsils, and roof of the mouth; livid exudation on 
tonsils and fauces, with hot, constrictive pain in the throat ; 
pain shoots into the ears when swallowing; very copious and 
annoying discharge of tenacious, stringy, ropy saliva from the 



96 SPECIFIC INFECTIOUS DISEASES. 

mouth; dull, frontal headache; aching in the back and limbs; 
very offensive breath ; weakness and dizziness. The tincture of 
the freshly gathered green root proved exceedingly valuable 
during the prevalence of diphtheria in northern Ohio, from 
1866 to '69. 

In the treatment of the local disease after the early stage has 
passed, the most useful remedies are : Mercury, Kali bichrom. , 
Ai'iMON. caustic, Phytolacca, Nitric acid, Chlorate of 
Potassium, Arum, Iodine, Apis mellif., Cantharides, and 
Sanguinaria nitr. 

Mercury: Mercurius biniodat. is usually adapted to the 
earh r stage of the affection, the purely inflammatory S3 r mptoms 
in the throat being the most conspicuous feature of the case, 
with considerable pain from swallowing. Merc, iodat. flay. 
covers similar symptoms, but the exudate at first appears in 
small patches, well defined, which make the posterior wall of 
the pharynx look as though dotted with many spots of ulcera- 
tion. After a time these coalesce, but remain soft, thick, yellow, 
and easily detached. The tongue is yellow, especially at the 
root; the tip and edges are bright red. There is much nasal 
obstruction, from scabs rather than from pseudo-membrane; 
copious flow of ropy saliva ; swelling of the external throat. 
The marked glandular enlargement constitutes the chief point 
of differentiation between it and the red iodide of mercury. 
Mercurius cyanatus resembles very closely the corrosive sub- 
limate, which, indeed, has made an excellent record. Under it 
the local inflammatory symptoms are intense ; the fauces, 
pharynx, larynx and nares, and often the entire buccal cavity, 
are covered with a tough, thick, leathery exudate, varying in 
color from a dark gray to afoul green or blackish brown. Flow 
of saliva is incessant, excoriating the lips and chin ; the nasal 
discharges are acrid and copious ; fetor of the breath is great ; 
skin hot and dry ; tongue parched and dry, sometimes covered 
with flakes of exudation ; the submucous tissues are involved ; 
infiltration of the neck may be pronounced. From the start 
the violence of the local symptoms arouses fear of eventual 
systemic infection, the more so since there is great prostration, 
very light pulse, haggard face, cold extremities, and feeble, irri- 
table action of the heart. In several successive and severe epi- 
demics in Michigan, in which the writer had abundant oppor- 



DIPHTHERIA. 97 

tunity for the study of the disease, no other indicated remedy 
yielded as satisfactory results, even when systemic infection of 
the gravest character was present. All these cases, however, 
were peculiar in the intensity of the local trouble, and the ab- 
sence of intense local inflammation was soon regarded as a 
counter-indication. 

Kali bichromicum ranks next. Raue's indications are 
good : "the discharge from the nose is tough and stringy ; pain 
in the left ear on swallowing ; swelling of the parotid glands ; 
croupy cough ; measle-like eruption ; red, raw, shining tongue, or 
tongue covered with thick, yellow coating ; deep-seated ulcera 
tion on the fauces ; mucus streaked with blood; fetor from the 
mouth; all symptoms worse after sleep." The exudation is 
yellowish- white or yellow, tough, firm, unyielding; copious, and 
extends into larynx and nares. Swelling of the cervical and 
submaxillary glands. J. S. Mitchell ( Arndt's System) is correct 
when he says " I am fully convinced that if these remedies (i. e., 
Mercury and Kali bichrom.), were used early and continued 
persistently, our cases of diphtheria would much less often pro- 
gress to the septic form." — Ammonium causticum. White 
exudate, tending to extension into the larynx ; hoarseness, even 
to aphonia ; croupy cough, threatening suffocation ; deep red- 
ness of the soft tissues of the upper pharynx, fauces and tonsils ; 
painful and difficult swallowing. Great weakness from the be- 
ginning, quite out of proportion to the duration of the disease ; 
fretfulness and restlessness; rapid, weak, wiry pulse. — Nitric 
acid. Violent fever; hemorrhagic tendency; great fetor of 
breath ; despondency. The throat looks as though painted or 
cauterized with silver nitrate. Ulcers in the mouth, very pain- 
ful; copious and acrid discharges; flow of thick, tough mucus 
from the corners of the mouth. Thin ulcerations remain after 
the exudation has disappeared. Splinter-like pain in the 
throat. High fever.— Chlorate of potassium. Very fetid 
breath; gangrene of the throat; violent pain in the throat; 
grayish- white and rapidly extending exudation. Mitchell ad- 
vises beginning with the second decimal trituration, rapidly 
increasing to teaspoonful-doses, every two or three hours, of a 
solution of one grain to the ounce of water ; if it fails to relieve 
promptly, discontinue its use. — Arum triphyllum Excessively 
acrid character of the discharges from the mouth and throat, 
7 



98 SPECIFIC INFECTIOUS DISEASES. 

excoriating the skin wherever they come in contact with it; 
lips swollen, raw and bleeding from constantly picking them ; 
great fetor of breath ; great restlessness ; extensive diphtheritic 
deposits, with ulcerative tendency. — Iodium. Thick, grayish- 
white exudation, with tendency to involve the larynx ; profuse 
salivation ; extensive glandular induration ; tenderness about 
the larynx ; difficult breathing ; croupy, laryngeal cough ; shrill- 
ness or hoarseness of the voice. Especially serviceable in dark, 
scrawny children of scrofulous diathesis. — Apis mellifica is use- 
ful when there is much oedema of the throat and uvula. Great 
and early debility; pufhness of the mucous membrane; diph- 
theritic patches on palate and uvula, of dirty grayish color; 
urine scanty, albuminous. "In laryngeal diphtheria it will 
moderate the oedema glottidis which, with the exudation, 
forms the cause of dyspnoea." — Sanguinaria nitrate. Intense 
burning in the throat, fauces and tonsils, especially on the right 
side, which is covered with membranous deposit. Copious, 
watery discharge from mouth and nares, mildly excoriating. 
It seems particularly adapted to persons subject to laryngeal 
catarrh, and in whom the diphtheria is intractable on account 
of the chronicity rather than the intensity of the symptoms. 

Systemic infection occurs much less frequently under the in- 
telligent and persistent use of the indicated remedy than it does 
under "aggressive" treatment by severe local measures. Of 
the remedies alreadj^ mentioned, Mercurius Cyanatus, Apis 
mellifica and Arum triphyllum often may be safely and 
advantageously continued into and throughout the stage of 
S3 r stemic infection, alwa^-s provided they are still symptomatic- 
airy indicated. The remedies most prominent here belong to 
that class which stands in close relation to septic and typhoid 
states, i. e., Arsenicum, Rhus toxicodendron, Lachesis, and 
Baptisia. Their symptomatic indications may be found in the 
chapter on typhoid fever. Under Arsenicum the exudation is 
grayish-white, with burning and pricking at the seat of the 
pseudo-membrane ; hemorrhagic and gangrenous tendency 
may be well pronounced. Salivation is profuse. — Rhus has 
blood}- saliva pouring from the throat; the parotids are 
swollen ; there is sticking pain in the tonsils ; the exudation is 
yellow ; the stools may be transparent, jelly-like. — Lachesis: 
Extreme difficult}- of swallowing ; lividity of the mucous mem- 



DIPHTHERIA. 99 

brane; exudation white or yellow; aphonia; great weakness 
from the start ; foul stools ; difficult and scanty expectoration. 
Sensitiveness of the neck to touch. The pain in the throat 
often is insignificant, although the appearance of the parts 
would seem to indicate severe suffering. He cannot keep the 
protruded tongue still ; it trembles and moves from side to side. 
The glands of the neck are hard and swollen. Swallowing of 
liquids more painful than that of solids. Restlessness; he 
changes position constantly to find relief from hard aching all 
over the body. Paralysis of the throat and of other parts. 
Constant low muttering delirium; great cardiac debility ; cold, 
clammy sweat ; coldness of the extremities. — Baptisia: Foul- 
ness of excretions and of secretions. Characteristic symptoms 
as given under "typhoid fever;" the throat is oedematous, 
looks foul and forbidding; yet, there is comparatively little 
acute pain, though swallowing usually is performed with much 
difficulty. — The Mineral acids should also be studied as possi- 
bly useful. Digitalis, Cactus, Amyl nitrate, and other cardiac 
tonics and stimulants must be employed -when heart-failure 
threatens. Gelsemium, Causticum, Arsenicum, Lachesis, 
Strychnia, Cocculus and Phosphorus are oftenest useful in 
the various forms of post-diphtheritic paralysis. 

Diphtheria-antitoxin. — Behring, Kitasato, Roux and others 
have demonstrated that the use of the blood serum of animals 
which have been artificially rendered immune against diphtheria 
may be successfully used in the treatment of diphtheria affecting 
the human family. A very large number of carefully made ob- 
servations in the chief public hospitals of Berlin, Paris, New 
York, Boston and other large cities seem to prove a remarkable 
reduction in the mortality rate of diphtheria, even to one-third 
and one-fourth of the accepted death-rate, in cases treated with 
diphtheria-antitoxin. It is, however, generally admitted that 
the treatment, in order to be successful, must be administered 
early in the disease, in fact during the first or second day after 
a diagnosis has been made; if not administered until after the 
third day of the disease, its effects are far less satisfactory. The 
antitoxin is given hypodermically, in the region of the flank or 
buttocks or between the shoulder blades, Behring's preparation 
usually being preferred. The dose is sixty antitoxin units 
(Behring's preparation No. 1) in the average case at the first 



100 SPECIFIC INFECTIOUS DISEASES. 

treatment; if the case should be severe or the patient is not seen 
at once, a dose of one hundred antitoxin units (Behring's prep- 
arationNo. 2) maybe administered; and in exceptionally severe 
cases one hundred and forty units (Behring's preparation No. 3) 
may be given. The dose may be repeated if improvement does 
not follow the first injection. 

Improvement shows itself in the amelioration of constitu- 
tional SA-mptoms, as fall of temperature and pulse, and in the 
disappearance of the membrane, a process which usually be- 
gins within twenty-four hours after the injection. In some 
cases such untoward results as erythema, urticaria, albumi- 
nuria and, more rarefy, local abscesses follow; these are not 
often serious. For purposes of affording protection against in- 
fection, an injection of one hundred to two hundred antitoxin 
normals may be administered to persons who have been ex- 
posed; the dose, according to Behring, ma}" be repeated in eight 
weeks. Statistics appear to prove the value of diphtheria- 
antitoxin as an immunizing agent. 



SCARLET FEVER.— SCARLATINA. 

General Description and Causation. — An acute infectious dis- 
ease, characterized b}^ a specific exanthem, high fever and sore 
throat. It is largely a disease of childhood, most frequently 
attacking children from the second to the tenth year; young 
infants, as a rule, escape ; exceptionally it occurs in adults. It 
is not confined to any race or country, but is comparatively 
rare in Asia and Africa and is reported to be unknown in 
Japan. Sporadic cases are not infrequent, but much oftener 
scarlet fever occurs in wide-spread epidemics, preferably in the 
fall, winter, and early spring. 

The disease rarely attacks the same person more than once. 
Exceptions to this rule exist, but reported second attacks com- 
monly are erythematous or septic rashes which closely resemble 
scarlet fever. 

The essential poison of the contagion has not yet been dis- 
covered. Presumably it does not develop until the exanthem 
appears ; it is known to be convej-ed principally, if not entirely, 



SCARLET FEVER. 101 

by means of the scales of epidermis which form during exfolia- 
tion. It clings to furniture, bedding, clothing — in fact to any- 
thing capable of affording it lodgment, — and is thus conveyed 
from person to person by contact. It is not extensively spread 
in the atmosphere. Water, milk, or any article proceeding 
from an infected room may become the carrier of the disease ; a 
convalescent may take it to the theatre, church or school, and 
a letter may carry it to distant parts. Predisposition or sus- 
ceptibility to it is not as general as to small-pox and measles ; 
it varies greatly in different persons, making it possible for an 
individual to convey the contagion from a patient to a third 
person without himself becoming the subject of infection. The 
specific germ is not affected by cold, but is killed by steam in 
motion (live steam) ; if not destroyed, it retains its virulence 
for years. The existence of an abraded surface or wound 
favors infection ; hence the special liability to it of women dur- 
ing the puerperium. Suckling and pregnancy protect against 
it. 

Examination after death reveals no specific structural 
changes or internal lesions save such as may be expected from 
the symptoms of the disease. 

Symptomatology. — The period of incubation, varying from 
two to seven, or more, days, having passed, the symptoms 
which mark the real onset of the disease are usually sudden in 
their appearance and violent in character. The child vomits, 
feels very ill, has fever which arrests attention by its intensity, 
and soon complains of sore throat. In other cases the onset is 
more deliberate, consisting of indisposition, slight chill followed 
by moderate fever, and accompanied with vomiting. Usually, 
however, the onset is sudden, and in quite young children con- 
vulsions may be present early or actually usher in the attack. 
The fever rises rapidly, and the thermometer may within 24 to 
48 hours mark a temperature of 104°, or higher. The face is 
flushed, and the skin very dry, pungent, burning to touch. The 
tongue is furred, the mouth parched, and the throat dry and 
sore. Within 24 or 48 hours a punctated rash appears, first 
on the lower neck, then on the breast (infraclavicular) and 
back, scattered, and resting on a "subcuticular flush" wholly 
hyperaemic in character ; it also appears as a vivid, red, puncti- 
form eruption on the oral mucous membrane, showing plainly 



102 SPECIFIC INFECTIOUS DISEASES. 

on the palate, fauces, and inner cheek. Within two da^-s the 
rash is fully developed and covers more or less thickly the 
entire body ; it is of a vivid scarlet, in its brightness unlike any 
other acute exanthem. Though frequently uniform, there are 
mam- cases where the eruption appears in patches, divided by 
normal skin, thus presenting a mottled appearance. In others, 
a tendency to papular elevations and roughness is noted ; or 
small miliary vesicles (scarlatina miliaris), resting on a deep- 
red background, cover the surface of the body ; or there may be 
petechias, numerous, of considerable size, and constituting one 
of the pathognomonic features of the malignant type. In 
some cases the eruption is very light or entirely absent. The 
characteristic feature of the eruption depends upon the marked 
hyperemia which instantly disappears from pressure, but re- 
turns quickh^ ; thus, with finger or pencil it is possible to trace 
upon the scarlet surface of the bod}-, especially upon the back, 
a sign, name or figure, whose whiteness strangely contrasts 
with the bright scarlet background. A similar contrast is 
often seen on the face, the lips and chin being pallid while the 
rest of the face is fairly ablaze. During the development of the 
eruption there is frequently much itching, but it is not exces- 
sively annoying at any time, and quite rarely so when the rash 
is fully out ; more discomfort is felt in cases where there is much 
swelling of the skin, the parts then feeling tense and uncom- 
fortable. 

The fever in the meantime continues high, without dropping 
of the temperature with the appearance of the rash ; it is ac- 
companied with a pulse varying from 120 to 150, or even 
higher, and rapid, superficial respiration. The tongue, coated 
and dry from the first, has assumed the " strawberry " appear- 
ance, due to swollen papillae, which as bright red spots dot the 
thickly-coated, white tongue; the tip and edges of the tongue 
are of a bright red. The breath is heavy, and there is fre- 
quently a sweetish, nauseating odor from the mouth. The 
urine is dark, scanty, slightly albuminous. The angina, of 
varying degrees of intensity, almost always causes much pain 
and annoyance. Vomiting usualh r ceases after two days, and 
food is then relished. The nervous symptoms, which may be 
very severe during the first two days, grow lighter as the rash 
fully develops. 



SCARLET FEVER. 103 

Within two or three days after its appearance, the eruption 
begins to fade, and passes away in the order of its develop- 
ment; the skin roughens, the upper layers begin to separate, 
first on the neck and chest, and finally desquamation occurs in 
large flakes (lamellae), the little patient during convalescence 
often finding much amusement from peeling off large strips of 
"dead" skin. This process lasts from ten to fifteen days, and 
may not be completed for three or four weeks. In favorable 
cases the general symptoms improve during the early part of 
the stage of desquamation; the lever at first shows marked 
morning remissions and then passes away by lysis. 

The throat symptoms deserve especial attention because of 
their pathognomonic importance and their bearing upon the 
prognosis. The pharynx is almost always affected. In very 
light cases there may be only redness and swelling of the soft 
tissues, with dryness and some pain in swallowing. In others, 
somewhat more serious, the parenchyma is involved, with 
much swelling and possibly the formation of small abscesses in 
the lacunae of the tonsils and ulceration; the latter may prove 
very annoying, owing to free bleeding from necrosed surfaces 
and occasionally circumscribed gangrene of the tonsils ; en- 
largement of the cervical lymph glands is frequent in this type. 
The most important and most threatening form of laryngeal 
affections, however, is scarlatinal diphtheria, a diphtheritic in- 
flammation of the tonsils and soft palate which appears on the 
third, fourth or fifth day of the disease. It presents the usual 
clinical history of dirty-colored, whitish spots, dotting the in- 
flamed mucous membrane, gradually increasing in size, and 
terminating in dry necrosis and ulceration. Extension of this 
process into the middle ear, nose and entire oral cavity greatly 
intensifies the pain and clinical importance of this form of 
diphtheritis. In addition, the cervical lymph glands swell 
enormously ; infiltration and oedema extend deep into the con- 
nective tissue, and in severe cases there is a thick, firm, 
"brawny" induration of the entire neck and floor of the buccal 
cavity. This type of angina is a common feature of some epi- 
demics and may well excite apprehension, since it is associated, 
not only with severe pain in the throat, but with high fever, 
severe constitutional symptoms, rapid exhaustion of strength, 
and such dangerous complications as oedema glottidis. 



104 SPECIFIC INFECTIOUS DISEASES. 

Varieties. — The following forms ma}^ be recognized: 

1. Abortive form. All the symptoms are mild. Usually 
lamellar desquamation; sometimes subsequent nephritis. 2. 
Fulminant form. Patient dies from the intensity of the intoxi- 
cation before the eruption appears. 3. Anginose form. The 
throat symptoms predominate. 4. Malignant form. Typhoid 
state. Hemorrhagic tendency. Collapse. 

While all cases of scarlet fever present the same pathogno- 
monic symptoms, there is yet great variety of expression in 
different individuals. In some cases the attack is exceedingly 
mild, while in the same family a brother or sister, as the result 
of the same exposure, may die within a few days, "individual 
susceptibility" to the disease determining the issue. The light 
cases may present the typical picture of the fever, but there 
may be no rash (scarlatina sine eruptione) and all the symp- 
toms may be trivial in character. It is, however, necessary to 
realize that the absence of severe symptoms is no guarantee of 
a speedy or perfect recovery ; on the contrary, every experienced 
practitioner knows that these light cases not infrequently 
develop complications of the most serious nature. 

The so-called malignant form of scarlet fever is characterized 
by great severity of the throat symptoms, by hemorrhagic ten- 
dency, and by intensity of the nervous symptoms. The throat 
symptoms have already been sufficiently described. Emphasis 
is to be placed upon the profound constitutional depression 
which usually accompanies them. They may appear quite 
early, may develop with startling rapidity, and may result 
fatally from acute blood-poisoning, from hemorrhage (as rup- 
ture in the coats of the carotid artery from separation of deep 
slough about the tonsils), from the formation of extensive 
abscesses, and from sheer exhaustion of the vital forces. The 
hemorrhagic form is found in feeble children, badly nourished 
and of slight powers of resistance. The skin usually is exten- 
sively involved, and epistaxis and hematuria are persistent 
and copious. Death takes place in two or three days. The 
ataxic or fulminant form presents the most perfect illustration 
of the destructive power of the specific poison. From the be- 
ginning the fever is very high (107° to 108°, or higher) ; there 
is intense headache, extreme restlessness, delirium, and coma. 
Convulsions commonly occur. Death takes place soon, often 



SCARLET FEVER. 105 

within 24 to 36 hours from the appearance of the first symp- 
tom. 

Complications and Sequelae. — Nephritis ranks highest in 
importance among the complications which may arise. Slight 
albuminuria, with a few tube casts and very rarely blood, is of 
common occurrence early in the disease, and has no special 
significance. The true scarlatinal nephritis does not develop, 
save in exceptional and rapidly fatal cases, until the end of the 
second or in the third week. It is generally preceded by, and 
for a day or two accompanied with, an increase of fever, some- 
times as high as 104°, with puffiness of the face and eyelids, 
oedema of trunk and extremities, in severe cases anasarca and 
even effusions into the serous sacs, more especially hydro- 
thorax. The urine exhibits characteristic changes; the 
amount secreted is scanty, and anuria may persist for many 
days. If the case is severe, a specific gravity of 1015 to 1025 
is reached; large amounts of albumin are present, and the mi- 
croscope shows red and white blood corpuscles, hyaline casts, 
renal epithelium, granules of haematoidin, etc. 

The duration of scarlatinal nephritis varies. In favorable 
cases it runs a course of from two or three to five, or more, 
weeks; sometimes, but rarely, it becomes chronic. Death occurs 
in the severest form from acute uraemia; in less aggressive 
cases dyspnoea (from ascites, hydrothorax, or pneumonia), or 
uraemic accidents, as cardiac failure, are responsible for the 
fatal issue; oedema of the glottis is a rare, but usually fatal, 
complication. 

The fact that this serious complication may arise during a 
light case necessitates frequent and accurate examinations of 
the urine, especially during convalescence. It is justly affirmed 
that the earlier in the case severe renal symptoms appear, the 
more serious the prognosis. The exhibition of remedies like 
Apium virus, Arsenic, and others, often yields most satisfac- 
tory results. 

Affections of the serous membranes give rise to grave com- 
plications. Here belong meningitis (in the early stage), 
pleuritis (with a pronounced tendency to become purulent, 
often occurring in connection with pneumonia), pericarditis 
(frequently overlooked), endocarditis (recognized chiefly by its 
valvular lesions), and scarlatinal synovitis or arthritis, usually 



106 SPECIFIC INFECTIOUS DISEASES. 

appearing during the subsidence of the fever, commonly at- 
tacking one joint and strongly tending toward suppuration. 

Pneumonia of the lobular form is a common complication of 
scarlet fever, especially when there is nephritis; it is of impor- 
tance chiefly because its presence embarrasses respiration. 

Ear-complications are very frequent; they often result in 
deafness, as shown by statistics from Asylums for the Deaf and 
Dumb. They are caused by extension of the inflammation in 
the throat through the Eustachian tube into the middle ear, 
followed by suppuration and perforation of the ear-drum. 
Further extension may lead to meningitis and brain abscess; 
or to paralysis of the facial nerve; or to disease of the mastoid 
bone. 

Intestinal disturbances (as diarrhoea and, rarely, dysentery) 
and enlargement of the spleen and liver, are common. Other 
complications and sequeke are: chronic enlargement and hard- 
ening of the submaxillary lymph-glands, paralysis, and, more 
rarely, melancholia, mania, diseases of the eye, gangrene, and 
noma. 

Diagnosis. — The most important considerations in the diag- 
nosis of scarlet fever are: its sudden onset and intensity; the 
early vomiting; the early appearance and the nature of the 
eruption; the continuance of the fever after the appearance of 
the rash; the strawberry tongue; the early appearance and 
constancy of the throat symptoms; the lamellated character 
of the desquamation; the frequent occurrence of nephritis and 
of ear-S3 r mptoms; the existence of other cases in the com- 
munity; the absence of a previous attack. 

Diphtheria. — In diphtheria the membrane appears early and 
is a constant symptom of the disease; it has a tendency to ex- 
tend into the larynx; involvement of cervical glands and of the 
ear are infrequent; nephritis is rare; post-diphtheritic paralysis 
common. It is now held by bacteriologists that the specific 
cause of diphtheria has been ascertained; hence, in all doubtful 
cases, especially when the existence of an erythematous rash 
confuses the diagnosis, a bacteriological examination should be 
had. 

Acute Exfoliating Dermatitis has: absence of scarlatinal 
throat symptoms. Involvement of hair and nails during des- 
quamation. Recurrence of the attack. 



SCARLET FEVER. ' 107 

Measles: Longer period of incubation; catarrhal symptoms 
precede the eruption; less violent onset; later appearance of 
the eruption (four days); character of the eruption (dark red, 
in patches, disappearing four days after breaking out); bran- 
like desquamation. 

Roetheln: Mild character and short course of the disease; 
mildness or absence of stage of invasion; usually the rash is 
darker than that of scarlet fever; there is catarrh of the nose 
and eyes, and only slightly sore throat. 

Septicaemia and Pyaemia: Absence of the scarlatinal angina; 
repetition of the chills; fitful temperature; greater enlargement 
of liver and spleen; protracted course; metastatic processes. 

Prognosis — The prognosis must be guarded, especially 
among the poor. The issue depends largely upon the nature of 
complications which may arise, the powers of resistance on 
part of the sick, and the care of the patient. In hospital prac- 
tice and among the poor, the rate of mortality in mild epi- 
demics is from 5 to 10 per cent.; in severe epidemics it ranges 
from 20 to 30 per cent.; among the well-to-do it is less. In 
children less than one year old scarlet fever is extremely fatal. 
The disease is more frequent from the second to the sixth year, 
hence that age figures conspicuously in the mortality tables. As 
stated, early and severe nephritis, inflammation of the heart or 
of its sac, pleuritis, severe diphtheritic angina, laryngeal ob- 
struction, haemorrhagic tendency, excessively severe and early 
nervous symptoms and unusually high fever from the very 
beginning increase the seriousness of the prognosis. 

Treatment. — Prophylaxis. — Since Hahnemann's recommen- 
dation of minute doses of Belladonna as an efficient prophy- 
lactic in scarlet fever this drug has been so employed by the 
profession generally. It is impossible to determine whether 
those are right who deny prophylactic virtue to all drugs and 
especially to Belladonna or if reliance can be placed upon the 
earnest assurance of others that by the use of Belladonna 
cases may be aborted or so modified as to prove compara- 
tively mild. 

The specific poison of scarlet fever is exceedingly tenacious, 
but the area of infection is very small, extending only a few 
feet from the patient. These two facts furnish the key to the 
only prophylaxis which appears to be of real value, i. e. perfect 



108 SPECIFIC INFECTIOUS DISEASES. 

isolation of the sick, strict quarantine of all who may become 
carriers of the infection, and thorough disinfection of the per- 
son of the sick, of everything he touches, of the sick room and 
its contents, and of all who come into contact with either. 
Intelligent and fearless action on part of Boards of Health, 
aided by the honest co-operation of medical men and of the 
public, will greatly lessen the frequency, the spread and the 
rate of mortality of epidemics of scarlet fever. 

As soon as an epidemic appears, or as soon as cases of scar- 
let fever are reported, those general measures for the protection 
of the public which are generally outlined by Boards of Health 
must be enforced. The house must be quarantined and the 
patient placed in a room removed from the apartments occu- 
pied by other occupants of the same house. A room in the 
top-story of the building is preferable. The removal of un- 
necessary furniture and of all articles of value which can be 
spared is obviously necessary. The care of this room is of the 
utmost importance. Its bared walls and floor, and everything 
in it, including patient, nurse, utensils, bed clothing, etc., must 
be constantly and conscientiously treated with disinfectants. 
Things of small value, as clothes, books, etc., which the patient 
has handled, should be burned at once. The air in the room 
should be kept as wholesome as possible by the use of such de- 
odorizers and disinfectants as have been suggested elsewhere, 
and nothing should be allowed to leave the apartment without 
being thoroughly disinfected, and then aired for a long time. 
After the recovery or death of the patient, complete disinfec- 
tion of the room must be undertaken by competent authority. 
Sulphur fumigation is more effective when the sulphur is burned 
over a wet sand-bath or when water is at the same time boil- 
ing in the room. The use of chlorine, freshly made by adding 
sulphuric acid to a mixture of salt and black manganese, is 
highly recommended. The walls may be rubbed with slices of 
fresh bread, which, according to bacteriologists, gathers up the 
microbes; after that, they should be whitewashed or calci- 
mined, and the floors and wood-work thoroughly scrubbed 
with a solution of corrosive sublimate. 

The throat and nares of the patient should be disinfected 
daily, both for his own comfort and for the safety of others; a 
spray of peroxide of hydrogen, 1 to 4 for the throat, and 1 to 



SCARLET FEVER. 109 

8 for the nose, is an excellent application. Physicians and 
nurses must see to it that they do not, by neglect of common 
measures of prudence, become disease carriers. 

The sickroom must be well-ventilated and kept comfortable 
for the patient; during the fever a temperature of 66° to 68°, 
and during the stage of desquamation or in case of nephritis 
of 70° to 73°, will prove suitable. The bedcovering should be 
light. The patient must be kept in bed for not less than ten or 
twelve days; he must not leave the room until desquamation 
has been completed. When allowed to go out, exposure and 
danger of taking cold must be scrupulously avoided. Cool, 
rather than cold, water may be drunk freely as the patient de- 
sires; bits of ice may be held in the mouth and swallowed. Diet 
must be nourishing and liquid; milk best answers the purpose, 
but broths, cocoa and fresh fruit may be used. Jaccoud is em- 
phatic in his declaration that a milk diet prevents nephritis. Ice- 
cream often is relished and agrees well. 

Hydro-therapeutics constitute the now fashionable and 
effective means of reducing hyperpyrexia. Showering or cold 
affusion, popular a few years ago, is no longer generally prac- 
ticed. The f ollowing directions will be found sufficient: Spong- 
ing of the face, forehead, neck and arms, with cold water to 
which may be added alcohol or vinegar, when the temperature is 
not above 102° or 103°. The cold-water bath may be used when 
the temperature is high, above 103°, but the pulse is full and 
strong, though rapid; capillary circulation is active, and the 
surface of the body of a bright, vivid color (asthenic cases); 
it must be avoided when the pulse is easily compressed, capil- 
lary circulation sluggish, and the surface of the body of a livid, 
dusky hue (asthenic cases) . If the hyperpyrexia is accompanied 
with marked nervous involvement, ice-bags, one-third full of 
ice, may be applied to the head until the temperature is reduced 
below 103°; or silk handkerchiefs, every few minutes wrung 
out of ice-water, to which vinegar or alchohol (1 to 5) can be 
added, may be used. If the temperature rises to 104°, or 
higher, the cold cloths may also be applied to the neck. Cold 
sponging of the extremities may be employed. If still more 
active measures become necessary, the forearms and hands 
may be covered with double thickness of sheets wrung out of 
ice-cold water. This treatment rapidly reduces the tempera- 
ture, and usually is agreeable to the patient. 



110 SPECIFIC INFECTIOUS DISEASES. 

In asthenic cases cold may be applied to the head and neck, 
but not to the extremities; the latter require hot water, with 
an abundance of friction, to accelerate the flow of blood and to 
stimulate functional activity. Bits of ice may be held in the 
mouth and swallowed. 

When there is frequent emesis, J. Lewis Smith uses an enema 
of ice-cold milk with peptonoids, every three hours. Alcoholic 
stimulants are kindly borne in asthenic cases, especially in the 
form of milk-punch or wine- whey. Smith calls attention to the 
safety of large doses of stimulants in scarlet fever and diph- 
theria, and recommends a teaspoonful of whiskey or brandy 
every one to two hours for a child of five years. This treat- 
ment is counter-indicated by the existence of scarlatinal neph- 
ritis. 

Therapeutics. — The great variety of S3 r mptoms found in 
scarlet fever and its manifold complications recalls the force of 
the maxim that in any given disease any one remedy in the en- 
tire materia medica may be indicated. In scarlet fever and in 
diphtheria, more than anywhere else, I have tested the value of 
close study of symptoms at the earliest manifestation of an 
epidemic, for the purpose of finding the "epidemic remedy." 
Thus, in the severe epidemic of 1868 (northern Ohio) I found 
Apis mellifica curative in a ve^ large majority of cases; in 
1872 (in central Michigan) both Arum triphyllum and Mer- 
curius cyan, did brilliant work throughout. The special use- 
fulness of these remedies in the epidemics cited depended in 
Apis upon the existing tendency to nephritis, in Arum and 
Mercury upon the prominence and type of the angina. 

In the abortive form Pulsatilla, Aconite, Gelsemium, 
Belladonna, and Mercurtus iodatus will probably cover the 
symptoms in a majority of cases. Pulsatilla is of very great 
value when the patient is "upset" rather than ill, complaining 
of shivering, slight fever without thirst, and stupid headache; 
inappetency, with slight nausea; past}' tongue; feverishness; 
tired and sleepy during the day, but restless at night; urine is 
scant}-, with frequent urging; the eruption is scant}'.— Bella- 
donna. The symptoms are more pronounced, the rash is uni- 
form, typical, but mild; fever and headache more violent than 
under Pulsatilla, and symptoms of general congestion, espe- 
cially in the throat, which is dry and hot, are more pro- 



SCARLET FEVER. Ill 

nounced. Winterburn (Arndt's System) verifies Jahr's observa- 
tion that Belladonna in the premonitory period delays the 
appearance of the rash. — Gelsemium, with much shivering, dull 
headache, dizziness, stupid and livid appearance of the face, 
great muscular weariness, especially in the legs; the eruption 
is smooth. — Aconite: high fever, sharp and rapid pulse, pun- 
gency of the skin to touch, dryness of the throat, great rest- 
lessness, with constant tumbling about in the bed from side to 
side. 

In the majority of cases, however, the disease will progress 
and the throat symptoms assume prominence; it is thus that 
the anginose form is seen more frequently than others. Here 
Mercurius cyan., Merc, iodatus, Kali bichrom., Phyto- 
lacca, Ailanthus, Arum, and Lachesis come into play. Con- 
sult also the remedies under Diphtheria. 

Mercurius cyanatus: Fetor from the mouth; tough and 
stringy salivation; painful deglutition; tough membranous 
deposits on the tonsils and on the pharynx; deep grayish 
ulcers, discharging foul, greenish-yellow pus. Rattling and 
whistling in the throat; hoarse cough; dry, hot skin; urine 
scanty, dark, without sediment. Its keynote is the predomi- 
nance of the local (throat) over the constitutional symp- 
toms.— Mercurius iodatus covers a similar condition, but is 
preferable (especially the yellow iodide) when there is marked 
glandular involvement, while the pharyngeal inflammation is 
less violent than under Merc, cyanat. — Hepar is indicated 
oftener than it is used. The nasal mucous membrane is in- 
volved; stitching pain into the ears, when swallowing; swell- 
ing of parotid and maxillary glands. Symptoms indicating 
extension into the middle ear; threatening nephritis. — Kali bi- 
chromicum: Tough, dark, firmly adhering membranous depos- 
its, extending into the nostrils, anterior mouth, pharynx and 
trachea; the parts not involved are intensely deep-red and 
swollen; expectoration of stringy, ropy, tough mucus. The 
fauces are covered with deep, offensive ulceration, with isolated 
patches of exudation; excoriating yellow discharge from the 
nose; pain in the ears when swallowing; involvement of cer- 
vical glands; "measly" eruption; tongue bright-red or covered 
with a thick, yellow coating.— Phytolacca: Tardy, dry, shriv- 
eled skin; to the hand it feels like coarse paper; the discharges 



112 SPECIFIC INFECTIOUS DISEASES. 

from the nostrils are acrid, excoriating; much like those of 
Arum; the tongue posteriorly is coated yellow, is fiery-red at 
the tip, brown on the sides; ash-colored, diphtheritic deposit, 
with copious salivation, hard swelling of glands, pains into the 
ears when swallowing, which is difficult. Restlessness, sleep- 
lessness; hands and feet hot, cannot keep them covered.— Arum 
triphyllum. The acrid, ichorous character of the discharges is 
one of the most striking and best indications; when from the 
nose, it excoriates the nostrils and upper lips to a degree which 
renders the patient extremely uncomfortable; the corners of 
the mouth are sore, cracked, bleeding; the child "works" at the 
mouth and lips in spite of the pain and bleeding caused. The 
tonsils are puffed and swollen, the throat livid, very sore 
(burning) and putrid; profuse flow of acrid saliva; all the 
parts are so sore to touch that it is almost impossible to in- 
duce the child to open its mouth; redness of the tongue, with 
large red papillae on it; swelling of submaxillary and parotid 
glands. The constitutional symptoms are marked. There is 
great nervous depression, restlessness, excitability; sleepless- 
ness; continuous fever; head hot; apatlry; delirium, at times 
wild and with a desire to escape. Rash dark, in patches, 
with much itching; "desquamation a second or third time, in 
large flakes, especially when the eruption comes out fully" 
(Lilienthal). Its beneficial action is said to show itself in an 
increase of urine.— Lachesis: Under Mercury, Phytolacca, 
and Kali the throat symptoms overshadow the constitutional 
symptoms; under Arum the3 r are of equal importance; under 
Lachesis and Ailanthus the local symptoms, though severe, are 
yet insignificant when compared with the gravit}^ of the co isti- 
tutional manifestations of the disease. Lachesis has diphther- 
itic deposits beginning in the left tonsil, spreading to the 
right; difficulty of swallowing, especially liquids; the throat 
looks as though it must be excessively painful, yet little com- 
plaint is made, because the patient is too ill to mind the throat 
much, though he quickly shrinks from external pressure; tena- 
cious, sticky saliva; tongue of a dirty j^ellow at the root, with 
red papillae, showing plainly the "strawberry" tongue; "map- 
tongue;" accumulation of dried mucus in the throat; purplish 
swelling of the submaxillary and parotid glands; suppuration 
of these glands, with discharge of thin, excoriating ichor. The 



SCARLET FEVER. 113 

constitutional symptoms are characterized by profound nervous 
prostration with muttering, loquacious delirium; stupor from 
which the child is roused with great difficulty and into which it 
as quickly relapses; it lies as though lifeless; aphonia, aphasia, 
greatly impaired powers of deglutition; fluids swallowed es- 
cape through the nose; trembling of the tongue when pro- 
truded; tardy appearance of dark, purplish eruption; ecchy- 
moses; passive, dark haemorrhage from the nose, mouth, and 
bowels; scanty, black urine; offensive stools; coldness of the 
surface of the body, or heat of the trunk of the body with 
coldness of the extremities.— Ailanthus is an important remedy 
in the anginose form of scarlatina, but, like Lachesis, covers 
even more fully the symptoms of profound constitutional de- 
pravity and exhaustion. The throat is dark, livid, and 
swollen; the tonsils are studded with numerous deep, angry 
ulcers from which exudes a scanty, fetid discharge; the child 
refuses to swallow; the tongue is dry, parched, cracked; the 
teeth are covered with sordes; external neck swollen and sensi- 
tive; pulse rapid and weak; skin dry and moderately hot; 
drowsiness drifting into a semiconscious state; the rash is 
tardy, copious, or scanty, livid, petechial, blistered; asthenia, 
with very marked sluggish capillary circulation. 

Local measures must not be neglected. The patient's condi- 
tion usually is such as to make gargling difficult or impossible; 
yet, the direct application of medicinal substances to the dis- 
eased surface is imperative; hence the value of the hand 
atomizer, preferably one with a hard bulbous tip. A solution 
of peroxide of hydrogen (1:3 or 1:4) is excellent. The same ap- 
plication, though weaker (1:8), warm, may be thrown into the 
nostrils, once in three or four hours. Use small glass syringe, 
with curved neck and bulbous tip. A solution of salt in warm 
water (1 drachm to a pint) is also recommended. 

If the cervical glands become very troublesome and the inflam- 
mation is of a low grade, an ointment of iodide of lead (1 
drachm to one ounce of lanoline) is helpful; if the inflammation 
is intense and suppuration cannot be avoided, use poultices of 
flax-seed and of slippery elm; the knife, when necessary. 

The malignant form of scarlet fever demands the exhibition 
of Ailanthus, Apium virus, Arsenic, Ammonium carbon., 
Lachesis, Rhus toxicod., Baptisia, and the mineral acids. 
8 



114 SPECIFIC INFECTIOUS DISEASES. 

Several of these have been discussed tinder "Typhoid Fever," 
which consult. To the indications already given for Ailan- 
thus and Lachesis nothing is to be added.— Rhus toxicoden- 
dron. In cases which show a tendency to a typhoid state. 
The fever is not excessively high; the eruption is dark, miliary, 
and the skin rough; tongue red, smooth, later brown and 
cracked, with red tip; mental operations and speech slow, 
tardy; delirium mild, drowsy; is always busy trying to do 
something which he has not the strength to accomplish; eyes 
appear "swimming, as if drunk." The tonsils are swollen, of 
dark, mahogany color, covered with tenacious, yellow mucus. 
Involvement of cervical glands, first left, then right, with sup- 
puration, copious discharge of offensive ichor (Raue: impure, 
deep cavity, as if one could see into the throat); extensive 
oedema and cellulitis. Tendency to erysipelatous involvement 
of the affected parts. — Arsenicum meets the case at any stage 
when the vitality of the patient yields and every symptom as- 
sumes a serious aspect. This may occur early in the disease, 
with tardy, insufficient development of the rash; or the rash, 
later, may suddenly fade and begin to disappear, with aggra- 
vation of all the symptoms; or serious complications may arise 
during convalescence. In either case the typhoid state will be 
well pronounced, with the Arsenicum restlessness, desire to be 
warmly covered, relief of symptoms from warmth, and aggra- 
vation from cold in any form, even from cold drink. There are 
petechia? and ecchymoses; the throat symptoms are characterized 
by burning pain and dryness, ulceration and gangrenous ten- 
dency. If there are present, additionally, symptoms of 
nephritis, oedema, dropsy, with scanty emissions of dark 
colored urine or anuria, Arsenic is still indicated. — Apium virus 
is of value when the typhoid state is well pronounced, but is 
not so grave as under Arsenic. The cedematous tendency, 
especially in the throat, is its most reliable indication; the 
throat itself is rose-colored, with a feeling as though it had 
been scalded or as of a bee-sting in it. Sense of fullness and 
difficulty of swallowing from the oedema. Fever high, erup- 
tion smooth, with itching and "stinging" sensation in the skin; 
tense oedema of the skin; sweating and drj^ness of the skin al- 
ternating with heat and coldness. Tongue drj% red, swollen, 
glossy. Dyspnoea and restlessness. Scanty emissions of dark- 



SCARLET FEVER. 115 

red urine. The remedy is of the greatest value when effusion 
has taken place into serous cavities or when "hydrocephaloid" 
symptoms exist. Under its action I have seen recovery in cases 
which seemed hopeless, with rolling of the head from side to 
side, squinting, suppression of urine, piercing shrieks, and 
coma. Triturations made from lumps of sugar upon which 
the poison of the bee had previously been deposited proved 
most satisfactory; an increase in the amount of urine voided 
was the first indication of improvement. — Baptisia has very 
decided throat symptoms; they are, however, largely the local 
expression of that "constitutional depravity" which is one of 
its most reliable indications. It causes diphtheritic inflamma- 
tion and ulceration in the throat, with great fetor of breath; 
offensive, stringy saliva; dry, sore tongue; with brown center 
and bright -red, shining edges; heavy, dull headache, with 
burning heat in the face; scalding, high-colored urine; pro- 
found depression, with characteristic delirium (see "typhoid 
fever"). — Arnica is indicated in asthenic cases with ecchymosis 
and hemorrhagic tendency; the trunk of the body is warm, 
the extremities cold; 'cough, with raising of small amounts of 
blood; frequent flashes of heat; great soreness all over. — Am- 
monium carbonicum is suggested by Raue for swelling of the 
right parotid and of the lymphatic glands of the neck; putrid 
sore throat; miliary form of eruption. Lilienthal recommends 
it in the miliary scarlatina of malignant type, with gangrenous 
putrid ulceration of the tonsils, covered with rapidly decom- 
posing, sticky, offensive muco-pus; upper half of the body cov- 
ered by eruption, with violent itching; or faintly developed 
eruption; stertorous breathing; involuntary defecation and 
urination; threatening paralysis of the brain, with excessive 
vomiting. Winterburn (Arndt's System) also speaks highly 
of its use in the malignant form. 

The mineral acids are to be carefully studied when the pros- 
tration of the nervous system is great and the typhoid symp- 
toms are well marked ("typhoid fever"). Opium is suggested 
by severe cerebral symptoms, with sopor, heavy snoring, and 
vomiting of cerebral origin. 

The fulminant form demands Belladonna, Hyoscyamus, 
Zincum, Cuprum, and Camphor. 

Belladonna here is indicated by intense cerebral congestion, 



116 SPECIFIC INFECTIOUS DISEASES. 

with violent convulsions, violent delirium, with attempts to 
escape, and violence in all the actions of the child. The face 
is red; the e3 r e-balls congested; the arteries throbbing; the heat 
of the head greater than that of any other part of the body; the 
congestion of the throat is intense, though the local symptoms 
are wholly overshadowed b\ r the nervous symptoms. Or there 
is extreme pallor of the face, rolling of the head in the pillow, 
occasional violent screams or low wailing; paralysis of the 
sphincters; thread-like pulse.— Hyoscyamus closely resembles 
Belladonna, but lacks the intense congestion and the violence 
of action; the excitement here seems to involve the general ner- 
vous system rather than the brain exclusively. The eyes are 
sparkling, bright, starting; the patient lies in a muttering 
semi-delirium, has a look as though his mind were "far away;" 
if roused, he answers incoherently and relapses into uncon- 
sciousness before the reply is finished. Breathing is oppressed, 
rattling; intense constriction of the throat, rendering degluti- 
tion difficult, almost impossible; tympanitic distension of the 
abdomen; paralysis of the sphincters.— Stramonium. Convul- 
sive movements confined to single groups of muscles. The right 
hand is constantly endeavoring to grasp imaginary objects in 
the air; paralytic trembling of the arms and hands; spasmodic 
jerkings of the limbs; pale, coppery-red or receding eruption, 
with intense itching and dry, hot skin; rattling respiration; 
talks incessantly, laughs, weeps, sings; is frightened at every- 
thing; great dryness of the throat, relieved by drinking; paraly- 
sis of the sphincters.— Cuprum. In acute hydrocephalus, often 
from suppression of the eruption. Delirium in which "fear" 
figures prominently; biting, striking. Violent spasms, with 
screaming, followed by great prostration; boring the head into 
the pillow; face purple; hands clenched; foaming at the mouth; 
spasmodic rolling of eye-balls. — Zincum, when the action of the 
poison centers upon the brain. The condition of the child seems 
almost hopeless. The patient is unconscious and motionless, 
save incessant twitching of single limbs, especially of the feet; 
the occiput is very hot, the rest of the head cold and covered 
with cold, clammy sweat; face pale, anxious, distorted; breath- 
ing superficial, but there is no rattling; sudden piercing, hydro- 
cephalic screams; urine scanty, blood}', involuntary; pulse 
thread-like; surface of the bod}' cold, bluish. — Camphora is now 



SCARLET FEVER. 117 

used by all physicians when a quickly acting, powerful medi- 
cinal stimulant is needed, and has largely taken the place of the 
once fashionable musk. Homoeopathic ally it is indicated when 
there is sudden retrocession of the eruption, with cold skin and 
complete prostration, "in desperate cases, with rattling in the 
throat; hot breath; hot forehead; hot perspiration; limbs cold 
and purple." (Raue.)— Stimulants may be used as indicated, 
and application of clothes wrung out of hot water, with fre- 
quent brisk rubbing of the extremities, must be perse veringly 
maintained. 

TREATMENT OK IMPORTANT COMPLICATIONS. 

Affections of the Ear are frequently of sufficient severity 
and importance to demand the care of an experienced special- 
ist. The general practitioner, however, by careful attention to 
ear symptoms during the fever can do much toward prevent- 
ing or lessening the danger of such complications. If there is 
much pain in the ear, laudanum and sweet oil dropped into it 
may at first be safe and give relief; or hot water, with a few 
drops of the tincture of Aconite, Belladonna or Laudanum, 
allowed to flow gently into the outer ear often greatly relieves 
the suffering; or heat externally applied by bags filled with 
heated bran, or salt, or hot chamomile flowers or hops, is very 
comforting. If the pain is intense, it may be necessary to use 
a 4 per cent solution of cocaine, to which an equal amount of 
laudanum may be added. If no relief follows, the pain in- 
creases, and bulging of the ear drum can be detected, paracen- 
tesis must be performed promptly, and repeated when ueces- 
sary. This operation, though of no magnitude, should be per- 
formed by the aurist; the after-treatment consists chiefly of in- 
flation of the ear by the ear-bag. Offensive discharges from the 
ear require the use of dry boric acid, of which a sufficient amount 
to cover a nickel may be gently dusted into the ear; by direct- 
ing the patient to move the head it can be brought into con- 
tact with the ear-drum. After careful cleansing of the ear by 
syringing with warm water (add to a wineglassful of water 
half a teaspoonful of boric acid) and then drying it, the fol- 
lowing may be used three or four times each day: dissolve in 
one fluid ounce of water two drachms of boric acid and gly- 
cerine; instill enough to fill the external ear. (J.Edward Smith.) 



118 SPECIFIC INFECTIOUS DISEASES. 

During the stage of acute inflammation the remedies indi- 
cated by the totality of symptoms will probably cover the 
local affection and the usefulness of Belladonna, Pulsatilla, 
etc., is readily called to mind. When suppuration has become 
established, Calcarea carbonica, Hepar, Silica, or Sulphur 
must be prescribed. —Calcarea is especially useful in persons of 
a strumous diathesis, easily exhausted from plrysical or mental 
effort, predisposed tc impairment of nutrition, with a tendency 
to glandular enlargements, sensitiveness to cold air, habitual 
dampness of stockings from moisture of the feet, and aggrava- 
tions from washing or bathing. Fat children who suffer from 
itching of the scalp, are inordinately fond of eggs, are ' 'pot- 
bellied," and have sour taste, sour vomiting, sour diarrhoea, 
are good calcarea-subjects.— Hepar is indicated by excessive 
soreness to touch of the affected part; the child cannot, or 
from oversensitiveness will not, endure touch of the inflamed 
parts, objecting even to the most carefully conducted dressing; 
mental depression, weakness of memory, "hasty speech," sensi- 
tiveness to cold air.— Silica, after suppuration has taken place, 
does much toward preventing its downward, destructive ten- 
dency. Thin, watery, ichorous pus of foul odor; the pus is 
mixed with blood or little particles looking like cheese; fistu- 
lous openings; rawness and soreness of the feet from constant 
copious sweating; aggravation from cold; amelioration from 
warmth. — Sulphur is credited with the power of exciting into 
action the vital forces when the}^ have begun to flag and thus 
fail to respond to the indicated remedy. It acts best in persons 
of rough, harsh skin, subject to eruptions of various kinds, 
with rawness and soreness whenever there is a fold of skin 
(axilla, groin, etc.), and whose body exhales an offensive odor 
which is not due to lack of cleanliness. Children who are good 
subjects for Sulphur usually have a large head with open fon- 
tanelles (Calcarea), and suffer from lack of assimilation; thej r 
are great eaters, yet remain scrawny and thin. Faintness and 
"goneness" at the stomach, craving for food, especially at 11 
A. M.; heat on the top of the head, with coldness of the feet. 
Flushes of heat, with coldness of the feet, and epigastric 
weakness. Cannot take milk ;the child vomits it up, curdled. — 
Other remedies to be consulted here are Mercury, Phosphorus, 
Arsenic, Aurum, Asafcetida. 



SCARLET FEVER. 119 

Scarlatinal Nephritis.— The patient, if a convalescent, must 
be returned to bed at once; the room must be kept at a tempera- 
ture of 72° to 75°, and every precaution taken not to let him 
take cold. His diet must be liquid, preferably milk; in fact, as 
has been pointed out, a milk diet throughout scarlet fever is 
said to greatly reduce the danger of the occurrence of this com- 
plication; broths in moderate quantity and starchy food may 
be allowed. An abundance of cool, but not cold, water will 
prove grateful to the sick and of benefit in flushing the 
kidneys. Hot baths (98° to 100°), for 15 to 20 minutes, are 
highly recommended. The patient, having been taken to bed 
after the bath, is warmly covered to stimulate sweating. If 
the attack is severe, and the bath agrees, it is to be repeated 
two or three times daily. If the patient strongly objects or 
becomes restless in the bath, it must be discontinued. Diapho- 
resis may also be produced by placing the patient in a chair; 
blankets are wrapped all about him, and under the chair, in a 
plate, a thin layer of alcohol is burned. Care must be exercised 
not to spill the burning alcohol and thus set the blanket on 
fire. Or bottles filled with hot water, wrapped in wet cloths 
or towels, may be placed for the same purpose, about the 
child in bed. Of medicinal diaphoretics, philocarpine is by all 
means the most efficient. It may be given by the mouth in 
doses of from ^ to ^r °f a grain to a child two years old, every 
four to six hours, repeated until the sweat glands, the salivary 
glands and the kidneys are excited into action. 

Apis has already been pointed out as one of our most valua- 
ble remedies here. The urine is scanty, dark-red, contains 
epithelium, casts, and blood. There is oedema, anasarca; 
waxy appearance of the surface; bronchial catarrh; difficulty 
of breathing; orthcpnoea; thirst (study also indications given 
above). — Arsenic in its pathogenesy presents every symptom 
of nephritis and has an excellent clinical record. The chief 
symptomatic indications are: dryness of the skin, which may 
be cold, but oftener is dry and hot; characteristic restlessness; 
emaciation; weakness from slightest exertion; seeming impos- 
sibility to rally; relief from warmth in any form; great thirst; 
nephritic urine. — Helleborus niger when in the course of this 
complication the brain becomes poisoned and the patient pre- 
sents stupidity almost to insensibility, with severe pain in the 



120 SPECIFIC INFECTIOUS DISEASES. 

head, compelling him to lie perfectly quiet; great thirst; diffi- 
cult breathing; excessive muscular weakness and prostration; 
rolling of the head in the pillow from side to side, with moan- 
ing, grinding of the teeth, squinting; the urine is very^ scanty 
and ver3' dark, almost black, with coffee-ground sediment. 

The following may also be consulted in exceptional cases: in 
nephritis, Terebinthina, Digitalis, Mercurius corrosivus, 
Kalmia, Asclepias syriaca; in the anginose form, Lycopo- 
dium, Kali carbon., Bromium, Baryta, Iodium; in mastoid 
complications, Phosphorus, Asa fcetida; in collapse, Carbo 
yegetab.; in the fulminant form, Acidum hydrocyanicum. 



MEASLES.— MORBILLI. 

General Description and Causation.— An acute, infectious, 
higluy contagious disease, characterized by symptoms of ca- 
tarrhal involvement and a peculiar eruption. It is largely a 
disease of childhood, especially after the first 3 r ear, though 
adults frequently have it, particularly those not protected by 
a previous attack. It occurs in sporadic and epidemic form, 
the latter much more frequently; it is liable to appear at any 
season of the year, but oftener during the cold months of 
late fall, winter and early spring. The contagion, suscepti- 
bility- to which is almost universal, is communicated chiefly 
through the breath and the nasal secretions; hence, possibly, 
the preference of measles for the respiratory organs. It ma}' 
be conveyed by a third person and by fomites. The disease 
has been propagated by inoculation with the nasal mucus. It 
may recur, though usually one attack confers immunity. 

Symptoms.— The period of incubation continues for ten or 
more days. The stage of invasion is characterized by symp- 
toms of "a cold," the patient complaining of shivering more 
or less fever, headache, rarely convulsions, loss of appetite, 
sneezing, watery discharge from the nose and eyes, with swell- 
ing and redness of the eyelids, often great sensitiveness to 
light, and cough. Moderately sore throat is frequently 
present. The catarrhal symptoms continue; the tongue is cov- 
ered with a heavy white fur, a few red papillae showing 



MEASLES. 121 

through the coating; the fever reaches a considerable height on 
the second and third day (102°-104°); usually on the third day 
the oral mucous membrane assumes a condition of, marked 
hyperasmia, showing a more or less clearly defined punctif orm 
rash, especially about the fauces. With the fourth day, the 
stage of eruption begins. This eruption consists of red pap- 
ules, usually small, sometimes as large as a split pea, slightly 
raised, sometimes "shotty" to the touch, but at no time involv- 
ing the deeper layers. It first shows itself on the face, and ex- 
tends downward, rapidly covering the neck, breast, trunk, and 
extremities; on the latter it is comparatively light and scattered . 
The face lacks that whiteness about the mouth which is so often 
present in scarlet fever. The eruption arranges itself so as to 
form blotches, with well-defined, rounded outlines, crescent-like 
in shape; this is particularly well-pronounced on the face 
and upper chest; it is more mottled and blotchy, as well as 
lighter, on the lower part of the trunk and on the abdomen. 
Viewed as a whole, the eruption is of a deep rose-color, almost 
crimson; purple rather than scarlet, resting on a hyperaemic 
base, with intervening patches of normal skin on the face and 
body, the hyperaemia disappearing upon pressure, to return as 
soon as pressure is removed. If the case is one of unusual 
severity, petechias may be present; it is, however, worthy of 
note that the petechial character of the eruption is often seen 
in cases of only moderate severity, some epidemics showing 
such a tendency; in other cases miliary vesicles may develop. 
The appearance of the eruption is not folio-wed by lessening of 
the fever or of the constitutional symptoms; on the contrary, 
the catarrhal state is maintained with little change for the 
better; the lymph-glands are swollen and sore, and the tem- 
perature remains high until the fifth or sixth day, when, 
usually, improvement in every respect shows itself. 

The period of desquamation begins within two or three days 
after the appearance of the eruption, desquamation proceeding 
in the order of the appearance of the rash, beginning on the 
cheek, forehead, face, and extending downward. It occurs in 
bran-like scales, so fine as to be almost invisible; they are best 
seen "when one brushes the skin of the patient with one's coat 
sleeve" (Trousseau). As the eruption disappears, the fever 
promptly decreases, the catarrh diminishes, and rapid conva- 
lescence is established. 



122 SPECIFIC INFECTIOUS DISEASES. 

Varieties. — Cases may abort, showing the general picture of 
the disease, but presenting no eruption {morhilli sine morbillis); 
this most frequently happens when an entire family is ill with 
measles and some members show only slight susceptibility to 
the contagion. Or the eruption may appear earlier than com- 
mon, even within thirty-six hours from the onset of the disease; 
or it is delayed to the fifth or sixth day. Under specially un- 
favorable conditions the haemorrhagic tendency may be 
well-pronounced, accompanied with very severe constitutional 
symptoms, great depression of the vital forces, and death from 
toxaemia. In civilized countries this form has almost disap- 
peared, save where the surroundings are bad or the patient, 
from a low state of health, such as is found among the 
neglected poor, readily falls a victim to any severe illness; thus 
in poor-houses and in camps this form {morhilli haemorrhagici) 
is often seen, while in private practice it is rarely met. It has 
also been observed that for the same reason native popula- 
tions, especially when first exposed to measles, suffer from the 
most virulent manifestation of the disease. The term typhoid 
form is merely a term of convenience, self-explanatory. The 
black measles of the older writers probably were cases of haem- 
orrhagic small-pox. 

Complications and Sequelae.— Measles, uncomplicated, is a 
comparatively harmless disease; but complicated, its death- 
rate is high. The early and extensive involvement of the re- 
spiratory system constitutes a source of great danger, espe- 
cially in weak or badly nourished children and in those who 
are placed among unsanitary surroundings; there the bron- 
chial catarrh ma3 r become intense, involve the smaller tubes, 
and rapidly lead to collapse of tissue or broncho-pneumonia. 
Membranous laryngitis not infrequently develops, and is 
always a dangerous complication; the pharynx may be simi- 
larty involved; cancrum oris and stomatitis are occasionally 
present in strumous children. Catarrhal affections of the eyes 
and ear, the former eventually purulent, the latter with a ten- 
dency to suppuration and perforation of the ear-drum, are 
common, and yield reluctantly to treatment. Or diarrhoea, in 
exceptional cases dysenteric in tendency, may become an annoy- 
ing feature of the case, at times even determining a fatal issue. 

The sequelae proper [really consist of those secondary affec- 



MEASLES. 123 

tions which are the result of great drain made upon a weak 
constitution, acting as the exciting cause of tendencies lying 
dormant, in the system. Thus, tuberculosis often occurs as a 
sequel in persons of phthisical tendency who have suffered 
from severe involvement of the respiratory organs; post-febrile 
forms of paralysis occur less often. In scrofulous subjects 
necrosis (of the jaw-bone), noma, the latter generally fatal, 
have been noted, but rarely. "Noma does not arise sponta- 
neously, but is preceded by some slighter lesion of the same 
parts, such as a decayed tooth, an inflamed gum, or an infan- 
tile leucorrhoea respectively." (Thomas.) 

Diagnosis. — This rests chiefly upon the presence of character- 
istic catarrhal symptoms, beginning early in the stage of inva- 
sion and continuing -well into the stage of desquamation; upon 
the continuance of the fever after the eruption appears; the 
lightness of the throat symptoms; the nature of the eruption. 
These alone are sufficient to distinguish measles from scarlet 
fever, especially so in the presence of epidemics of one or the 
other. The diagnosis from roetheln often presents great diffi- 
culty, and may be impossible. Of drug-eruptions, that of 
copaiba and of several antipyretics resembles morbilli, but 
there is absence of catarrh and fever. Coryza has much less 
fever, no exanthem. Hay- fever occurs in repeated attacks, at a 
season of the year when measles is not liable to be found, and 
has no exanthem. 

Prognosis. — The disease itself is rarely fatal, but the gravity 
of several of the complications seriously affects the prognosis. 
It is stated by Thomas that in the first six months of life the 
disease generally is mild; later in infancy, especially during the 
next year, it is much more serious. Pregnant and lying-in wo- 
men, as well as feeble, old people, are usually very ill. Fagge 
gives the mortality of measles as varying from 2 or 3 per cent, in 
some epidemics to 50 per cent, in others. Trousseau lost with 
broncho-pneumonia twenty-two out of twenty-four children 
under his care in the Necker Hospital (1845-1846). As pointed 
out, in camps and hospitals an outbreak of measles is to be 
dreaded and the prognosis is much more serious than in private 
practice. 

Treatment— Prophylaxis is practically out of the question, 
owing to the volatile character of the specific poison. The dis- 



124 SPECIFIC INFECTIOUS DISEASES. 

ease is communicated by the breath of the patient and by 
exhalations of his body. Slight danger, if airy, exists of com- 
munication by- a third person or by articles from the sick-room. 

The patient must be kept in a well-ventilated room of about 
70°, in which the air should be kept slightly moist and from 
which direct light has been excluded; he should be isolated as 
far as circumstances permit and put upon an easily digested, 
nourishing diet, preferably liquid, as milk. If the eruption is 
tarch^ in coming out, the time-honored custom of giving warm 
drinks and a hot bath is to be followed. If the fever is quite 
high, spcu ging or bathing in tepid water may be practiced. 
Great pains must be taken to keep the sick one away from cur- 
rents of air, since "a cold" is a very serious thing at any stage 
of the disease, and there is special susceptibility to taking cold 
during the stage of eruption. During desquamation, the use of 
oil on the skin and of warm baths is advantageous. Every 
precaution must be taken throughout convalescence to prevent 
taking cold. Stimulants may be demanded in exceptionally 
severe cases when there is fagging of the vital forces, and in 
cases of pronounced cachexia from poor living or other causes. 

In the simple, uncomplicated case medication is said to 
be of secondary importance. Yet, the clearly indicated 
remedy will relieve existing S3 r mptoms, ward off compli- 
cations, and hasten recovery. Here, Pulsatilla, Gelsemium 
and Aconite are most frequent^ useful. 

Pulsatilla so completely covers the catarrhal and gas- 
tric symptoms which almost from the start accompany^ measles, 
that in cases with moderate fever and slight gastric uneasi- 
ness no other remedy may be required. Pulsatilla has cor^-za, 
now fluent, then dry; sneezing; congestion of the eyes; irritated 
and inflamed, itching eyelids, often with profuse lachryma- 
tion. Frequent cough, dry during the day, loose at night, 
especially after lying down; the child insists upon sitting up in 
bed while coughing. Earache; loss of appetite; vomiting of 
mucus after coughing. Fever, with heat in the head, diwness of 
lips, absence of thirst, diarrhoea. It is useful also later on, 
when the gastric symptoms are more troublesome, and there 
is gastric and abdominal flatulency, vesical irritation, difficult 
breathing, ringing in the ears, deafness and semi-purulent or 
purulent character of the discharges. 



MEASLES. 125 

Gelsemium is useful when the sense of chilliness or shiver- 
ing is followed by high fever, with drowsiness, heavy stupid- 
looking face, darkly flushed countenance, great muscular 
weariness and soreness. Sensitiveness of the eyes to light; 
dizziness. Pulse soft, full, slow; tongue covered with a thick 
whitish or whitish-yellow fur. Watery discharge from the 
nose, at times excoriating the nose and lips; rawness in the 
throat and chest, plainly, and at times painfully, felt when 
coughing; cough hoarse, barking. There appears to be a low 
form of congestion, affecting brain, chest and abdomen. The 
eruption is dark, livid. 

Aconite is called for less often, though pointed indications 
for it may be present at the beginning. It has coryza with 
pressive pain at the root of the nose; sneezing; dry, short, hard 
cough, with tickling in the throat; stitching pain in the chest; 
high fever, with pungent skin, full, hard, quick pulse, and char- 
acteristic restlessness and thirst. 

If the catarrhal condition wholly overshadows other symp- 
toms, and the respiratory organs eventually become more 
deeply involved, Gelsemium and Pulsatilla may still be indi- 
cated, but there will also come into play remedies like 
Euphrasia, "Bryonia, Kali bichromicum, Hepar, Ipecacu- 
anha, Antimonium tartaricum, Phosphorus. 

Euphrasia is of value chiefly when the eyes suffer to an 
unusual degree. There is great sensitiveness of the eye to light, 
and a constant discharge of hot, acrid tears; bland, watery 
discharge from the nose. The local use of this remedy is rec- 
ommended in connection with its employment internally, in 
proportion of one drachm of the mother tincture to four ounces 
of tepid soft water. The remedy has also marked respiratory 
(catarrhal) symptoms. 

Bryonia is indicated by slow development of the eruption 
and symptoms of bronchial irritation or inflammation, with 
dry, painful cough; jarring pain in the head and stomach from 
coughing; rheumatic pain in the chest and limbs; quick, super- 
ficial, catching breathing; yellowish-white coating of the 
tongue; absence of thirst or very great thirst; severe headache; 
constipation.— Kali bichromicum: Fluent, acrid coryza, ex- 
coriating lips and nose; watery discharge from the eyes, which 
burn when opened; swelling of the external auditory meatus, 



126 SPECIFIC INFECTIOUS DISEASES. 

with violent stitching pain extending from the ear to the roof 
of the mouth and to the parotid on the affected side. Loud, rat- 
tling cough, with difficult expectoration of tough, stringy mucus; 
roughness of the larynx, with hoarseness; wheezing and rattling 
in the throat and chest, when sleeping. Later the catarrhal dis- 
charges become purulent; thus, from the nose: thick, greenish dis- 
charge, with sensitiveness and ulceration of the nostrils; from 
the eyes: purulent discharge; the cornea is inflamed, and pus- 
tules form on it; the ear: discharge of offensive mucus.— Hepar: 
Sharp, darting pain in the ears, with crackling noise in them 
when blowing the nose; hoarse, croup}- cough, with rattling in 
the chest, but no expectoration; roughness and scraping sensa- 
tion in the throat. Eruption comes out slowly; is pale. — 
Ipecacuanha: Incessant, dry, tickling, teasing cough, with 
rattling of mucus in the chest; great difficulty of breathing; 
face pallid or purplish-blue. The eruption is tardy.— Antimo- 
nium tartaricum: Chilliness, with sneezing and fluent coryza. 
Great oppression in the chest; he coughs often, and it sounds as 
though the chest were filled with mucus (loose rales), but he 
cannot raise anything. Cough followed by yawning, espe- 
cially in children. — Phosphorus. The voice is hoarse and 
rough. The cough is drj', tickling, exhausting, and there is a 
sense of great tightness in the chest, with relief from external 
pressure. Cough worse from speaking or laughing. Involve- 
ment of the lower lobes. Watery diarrhoea. Typhoid condi- 
tion. 

Other remedies which may be indicated are: Sulphur: Erup- 
tion tardy; lack of response to indicated remedy; condition 
threatens to become chronic; dry, hacking cough, especially in 
the evening, when rying down; with itching in the bronchi, 
stitching pain in the throat when swallowing, and stitching 
pain in the chest, extending back to the scapula; broncho- 
pneumonia. — Sticta: Incessant dn^ cough; racking, spasmodic 
cough, excited by inspiration; from tickling in the (right) side 
of the trachea; oppression of the chest; worse during the eve- 
ning and at night. — Mercurius: Coryza; sneezing without re- 
lief; profuse flow of tears; phar\-ngeal inflammation; intestinal 
catarrh; soreness in the chest, with deep hard cough and ex- 
pectoration of foul, purulent matter. — Drosera: Paroxysms of 
cough, sounding like whooping-cough, after measles; worse in 



RUBELLA. 127 

the P. M.; occasionally attended with bloody, purulent expec- 
toration. 

In addition to these remedies, flax-seed tea, slippery elm, 
solutions of gum arabic, and other demulcent drinks, cold or 
hot, may be freely given. A layer of flannel with oiled silk 
may be applied to the chest, the chest being also bathed in 
camphorated oil. These measures do not in any way interfere 
with the action of the remedies, and by keeping the chest warm 
and producing a slight irritation there, the eruption may be 
brought out more fully and maintained for a proper length of 
time, thus greatly relieving the respiratory system. 

Belladonna, Bryonia, Cuprum, Stramonium, possibly Zin- 
cum, will prove useful when at any time, from retrocession of 
the rash or from other cause, violent cerebral involvement 
occurs.— Arsenicum, Rhus tox., Lachesis, Crotalus, Cam- 
phor, when malignancy of the disease produces marked ner- 
vous prostration, typhoid state or collapse. 

For the special treatment of complications or sequelae consult 
the respective chapters under which they are discussed. 



RUBELLA. 

Synonyms: Roetheln; German Measles; French Measles. 
Rubeola notha. 

An acute, infectious disease, characterized by the absence of 
well-defined initial symptoms, an eruption resembling that of 
measles, catarrh, and enlargement of the lymph-glands. 

A micro-organism, not yet isolated, is the cause of this mildly 
contagious affection, which may be conveyed by a third per- 
son, fomites, etc. It attacks persons of all ages, but shows a 
decided preference for the young, seventy-five per cent, of the 
cases occurring before fifteen years of age; infants are rarely 
the victims. 

The period of incubation covers the unusually long period of 
from ten to twenty, and even more, days; the stage of inva- 
sion is proportionately short, rarely more than twelve to eigh- 
teen hours. The most striking feature of the disease is the 



128 SPECIFIC INFECTIOUS DISEASES. 

eruption, the appearance of which is in some cases preceded by 
malaise, moderate elevation of temperature, some catarrhal 
involvement of the conjunctiva, nose, pharynx, and larynx, 
and swelling of the cervical lymph glands; in others the erup- 
tion is the first symptom observed. The rash appears as 
minute, deep or bright rose-red spots, smaller than measles, 
circular, and rarely presenting the crescent-like form of mor- 
billi; they are slightly elevated, and almost always discrete. 
Their appearance has been described as "dark-red, with pen- 
points in white blotting paper." They are first seen on the fore- 
head and temples, and spread downward over the face, chest, 
and body. The eruption remains rather longer than that of 
measles, but usually on the third day fades and disappears 
without decided desquamation; in some cases I have observed 
bran-like, scurfy desquamation; the skin is left slightly 
stained. The constitutional symptoms vary in severity, though 
they are hardly ever intense. In some cases the temperature is 
scarcely affected; in others it may be as high as 101° or 102°, 
and may remain so for two, rarely more, da}'S. Occasionally 
the fauces are considerably congested, in which case there is a 
visible exanthem of the fauces and pharynx; in others, symp- 
toms of conjunctival, nasal or la^ngeal catarrh are f airly pro- 
nounced. Again, the lymphatics may be considerably enlarged, 
involving not only the cervical, but other lymph glands as well. 
These enlargements do not continue long. Quite often the con- 
comitants are so insignificant as to escape notice. While in 
weakly, badly nourished subjects complications may arise 
here, as in other exanthematous fevers, rubella is singularly 
free from complications and sequelae, and runs so mild a course 
that the prognosis of the disease is absolutely favorable and 
treatment of any kind is required in exceptional cases only. 

In differentiating rubella from measles, the history of the 
case as to previous attacks of measles, the brevity of the stage 
of invasion, the early appearance of the eruption, the mild 
character of the catarrhal s\'mptoms, the comparatively ex- 
tensive involvement of the h^mph glands, the trivial character 
of the fever, and the absence, usually, of a proper stage of des- 
quamation, must establish the diagnosis of rubella. If any 
treatment is deemed advisable, the measures recommended in 
the preceding'chapter (measles) may be employed. Isolation 
of the patient is always advisable. 



129 



VARIOLA.- SMALLPOX. 

General Description and Causation.— An acute, infectious 
disease, whose onset is characterized by rigor, fever, headache, 
and severe pain in the loin, and whose most striking feature 
consists of an eruption which passes through well-defined 
stages of development to maturation and crust formation. 

The disease spares no age, sex or race. In former times wide- 
spread epidemics of smallpox were of frequent occurrence, with 
a mortality of from 80 to 90 per cent, among the more intelli- 
gent nations, and entirely wiping out of existence aboriginal 
races. The protection afforded by vaccination and modern 
methods of treatment have robbed the disease of its old-time 
terror. 

The specific virus or poison of the contagium is as yet un- 
known. It is volatile, for direct contact with the patient or 
infected matter is not necessary to produce the disease. It ex- 
ists in the exhalation from the lungs and skin and in the excre- 
tions. It may be conveyed from person to person, by direct 
contact or by fomites. Its virulence is such that carriages, 
street cars, berths of steamers or railway trains, occupied by 
one sick with the disease, even during the period of incubation, 
long before the appearance of pustules, are sure to communi- 
cate it to persons later occupying them. Infection from a very 
mild case may give rise to a severe form of smallpox. It rarely 
attacks the same person twice. 

Symptomatology. — The stage of incubation, usually covering 
a period of from seven to twelve days, is folio-wed by the stage 
of invasion, of which a rigor, more or less severe, and occa- 
sionally repeated during the next twenty-four hours, is the 
initiatory symptom in adults, while in* children it more com- 
monly begins with convulsions. Intense frontal headache, 
severe pain in the back and limbs, anorexia and vomiting fol- 
low; the backache and the pain in the legs are intense; in fact, 
more so than in any other eruptive fever. Fever now declares 
itself; the pulse is rapid, full, rarely dicrotic; temperature 
rises quickly, and may even on the first day reach 103° or 
104°; the skin is dry, hot, pungent, free sweating occurring 
9 



130 SPECIFIC INFECTIOUS DISEASES. 

in exceptional cases; restlessness and sense of general distress 
are marked; delirium may be pronounced if the fever is high; 
in children, under the same condition, convulsions may 
continue. On the second or third day the initial rash may ap- 
pear, a diffuse (scarlatinal) or macular (measly) erythema, 
which usually is limited to the lower abdomen, inner surface of 
the thighs, lateral thoracic regions and axillae, but may be gen- 
eral. On the fourth day, sometimes at the end of the third 
day, the stadium eruptionis begins, accompanied by decided 
lessening of the fever and of the constitutional symptoms. 
Small red dots show on the face (especially at the junction of 
the hair) and wrist, and within twenty-four hours cover the 
trunk, arms, and legs. On the fifth and sixth day these 
change into papules (stadium floritionis) which convey to the 
hand passed over them a soft, satin-like "feel." On the top of 
these, vesicles form, the whole papule being elevated, circular, 
and slightly depressed in the center (umhilication) . These 
vesicles enlarge, umbilication disappears, the flat top rounding, 
and their contents assume a grayish-3'ellow color, due to the 
presence of pus (stadium suppurationis) . The pustule itself is 
surrounded by an area of intense redness, and a generally 
oedematous condition of the surface prevails. The papules 
having appeared first on the face, the formation of pus begins 
there, progressing in the order in which the eruption developed. 
The formation of pus on so large a portion of the surface of 
the body causes a rise of the fever (the secondary fever ol 
variola) and a return of constitutional accompaniments. The 
pustules increase in size, and the swelling and tension of the parts 
give rise to much distress and pain, especially in the face. The 
appearance of the patient at this stage is repulsive. The eyelids 
are swollen and the eyes closed; the lines of the face and its 
natural expression are obliterated; the hands are intensely in- 
flamed, especially on the dorsal surfaces. The eruption is least 
troublesome on the "femoral triangle" of Simon (hypogas- 
trium and inner surfaces of the thighs). The mucous mem- 
brane now becomes involved (mouth, throat, tongue, soft 
palate, nares, larynx, trachea, oesophagus), being studded 
with small superficial ulcers which ma}' become confluent, and 
always cause pain, soreness and swelling, with difficulty of 
breathing and swallowing and, in case of laryngeal involve- 



VARIOLA. 131 

ment, temporary loss of voice. The rise of temperature con- 
tinues for twenty-four hours, rarely longer, and then drops to 
about 100°. 

On the tenth or eleventh day, sometimes not until the thir- 
teenth, convalescence begins. Many of the pustules have burst, 
emptying their contents and thus affording relief to the painful 
tension and tightness of the skin. Yellow crusts form, and 
within a few days these crusts and scabs begin freely to fall 
off {stadium exsiccationis) . This process is accompanied by in- 
tense itching of the skin, often a source of the greatest discom- 
fort to the patient. Pigmented spots remain for a long time, 
and in case of deep ulceration, involving the cutis vera, a per- 
manent scar is left. This is the general history of the discrete 
type of smallpox. 

The confluent form presents the same initial symptoms, but 
in a majority of cases is characterized by greater intensity of 
morbid action and correspondingly greater danger to life. Syd- 
enham laid down the general rule that the more freely the erup- 
tion shows itself before the fourth day, the more sure to prove 
confluent. In some cases the papules are at first isolated, and 
show no tendency to become confluent until pus is forming. 
More frequently the hypersemia of the skin is intense from the 
start, and the papules are thickly scattered over the face, hands 
and feet, though much less so on the limbs and, especially, on 
the trunk. All observers subscribe to Sydenham's statement 
"if upon the face they are as thick as sand, it is no advantage 
to have them few and far between on the rest of the body." 
Pustules form, here as in the discrete type, with the same sec- 
ondary fever; but the hyperaemia is so intense and the -whole 
process so typically destructive that even before its completion 
confluence takes place, and all the face and the extremities form 
one large superficial abscess. Fever and constitutional symp- 
toms are severe, the temperature reaching 104°, the pulse 120, 
and active delirium often existing. There is much thirst, with 
salivation in adults and diarrhoea in children. The ulceration 
of the mucous membrane is persistent, and the cervical and 
lymphatic glands swell. In case of recovery, desiccation begins 
on the eleventh day, and progresses very slowly, occupying 
two or three -weeks; the fever may continue throughout the 
third week. In fatal cases a change for the worse shows itself 



132 SPECIFIC INFECTIOUS DISEASES. 

about the eleventh day; the pulse becomes rapid and weak, 
hemorrhagic symptoms occur, and death takes place from ex- 
haustion. 

Hemorrhage into the papules or pustules may occur at any 
time without necessarily increasing the gravity of the prognosis. 
Persons who are deficient in powers of resistance, as aged peo- 
ple or persons debilitated from illness or vicious habits, readily 
suffer thus. A very serious form, however, is the so-called 
Black small-pox (variola hemorrhagica pustulosa) in which 
the disease from the start assumes a threatening severity, and 
where, in addition to the hemorrhagic character of the exter- 
nal eruption, the same process takes place in the mucous mem- 
brane at large and in the internal organs. This type is quickly 
fatal, death taking place within two to five or six da^'s. 

The term purpura variolosa is applied to a type more fre- 
quently found in young, vigorous, full-blooded persons, men 
oftener [than women, in -which the hemorrhagic tendency is 
acute in character and manifests itself from the beginning of 
the disease. In these cases the usual early symptoms of small- 
pox are quickly followed, even on the second or third da}-, by 
cutaneous ecdn-moses which increase in size with startling 
rapidity, quickly succeeded by, or accompanied with, effusions 
of blood into the conjunctive and bleeding of internal organs, 
giving rise to hematuria, hematemesis, hemoptysis, and 
melena. So extensive are the cutaneous ecchymoses in some 
cases as to give to the patient a plum-colored appearance. The 
pulse is rapid and small; breathing superficial, and in its fre- 
quency out of proportion to the intensity of the fever; there 
ma}' be delirium, but often the mind is clear to the end. In 
these cases a fatal termination may be reached before the 
eruption proper has appeared. 

Varioloid is that form of the disease which occurs in persons 
who by previous vaccination are protected against smallpox 
proper. It is simply variola, modified. It ma}' come on grad- 
ualh- or its onset may- be sudden; in either case the fever is 
fairly high, often reaching 103° quite early, and the headache 
and backache are severe. The papules appear on the third or 
fourth da} r , are discrete, rarely numerous, and commonly con- 
fined to the face and hands; their appearance is followed by im- 
mediate relief of constitutional symptoms. The papules rapidly 



VARIOLA. 133 

pass to maturation; owing to the moderate excitement which 
accompanies the limited pus-formation, secondary fever is 
trivial, recovery prompt, and scarring rare. 

Complications. —The larynx often becomes diffusely in- 
volved; there may be extensive necrosis or fatal oedema. The 
lack of sensibility in the larynx may be such that particles of 
food are allowed to reach the lower air passages and excite 
bronchitis and broncho-pneumonia; the latter affection is com- 
monly found in examinations, postmortem; pletiritis is rare. 
The pharynx is frequently the seat of extensive ulceration, and 
pseudo-diphtheritic angina develops in many severe cases. Of 
the affections of the heart, myocarditis is the more common. 
The pressure upon the nervous system is marked. In the earlier 
stages convulsions are frequent in children; in severe cases of 
adults there may be delirium with tendency to coma. Post- 
febrile insanity and various forms of paralysis have been noted 
during convalescence. Orchitis and ovaritis occur; true neph- 
ritis is rare; albuminuria is frequent. 

Painful boils, erythematous conditions and even gangrenous 
inflammations often and for a long time continue a source of 
annoyance and suffering. There may be arthritis and necrosis 
of bone. Otitis media results from extension of inflammatory 
action through the Eustachian tubes. Affections of the eye, 
though not always avoidable, are usually the result of indiffer- 
ent care of the eye during the height of the disease, purulent 
discharges being allowed to come into contact with the con- 
junctiva, resulting in purulent conjunctivitis and even diffuse 
keratitis, possibly with ulceration and perforation. 

Diagnosis.— The only difficulty in diagnosis depends upon the 
close similarity of smallpox, especially of the severe type, dur- 
ing the stage when the eruption is forming but has not yet be- 
come pronounced, to very severe cases of scarlatina, measles, 
cerebro-spinal fever with purpuric symptoms, glanders of the 
pustular form and, in rare cases, syphilitic eruptions; in such 
cases patient watching for the appearance of pathognomonic 
symptoms and a careful estimate of all the circumstances of the 
case can alone finally establish the diagnosis. 

Prognosis.— In persons not protected by vaccination the 
prognosis is always serious; statistics show that in this class 
the mortality ranges from 20 to 35 per cent. The severe con- 



134 SPECIFIC INFECTIOUS DISEASES. 

fluent form, especially in children, is always dangerous, partic- 
ularly so when maturation is delayed and hemorrhagic effu- 
sion occurs. The possession of sufficient vitality to stub- 
bornly resist the morbid action is greatly in favor of the pa- 
tient, and those who lack in this direction, as persons who are 
debilitated from previous illness, or from old age, or from 
vicious living, furnish a very large mortality. Hemorrhagic 
effusions are always to be dreaded and are almost surely fatal 
when the constitutional symiptoms are grave. If on the start 
the pressure upon the nervous system is profound, the fever un- 
usually high, delirium marked, and subsultus present, the out- 
look is discouraging. The existence also of severe laryngitis or 
pharyngitis and, in women, of pregnancy- greatly complicates 
the issue. 

Reference has already been made to Sydenham's well-proved 
declaration that abundant eruption on face and hands always 
indicates danger; to this may be added the statement of 
Rhazes, "when the fever increases after the appearance of the 
pustules, it is a bad sign; but if it is lessened on their appear- 
ance, that is a good sign." 

Treatment. — Prophylaxis. — Prominent among all prophy- 
lactic measures stands vaccination, the inoculation of man 
with cow-pox for the prevention of smallpox. The inoc- 
ulation may be performed at any time, preferably in infancy be- 
tween the third and sixth month, and, to give perfect immunity, 
should be repeated at periods of five or six years. At the out- 
break of an epidemic, vaccination or revaccination should be 
performed at once. "Points of selection for the operation are 
about the insertion of the deltoid or the junction of the heads 
of the gastrocnemius muscles. In protection against future 
carelessness regarding revaccination, the matter may be intro- 
duced at three places, at the angles of a triangle at least half 
an inch distant from each other. Six or eight parallel trac- 
ings or strokes, with as many cross strokes, with the point of 
a knife, so light as to expose the superficial lymphatics and 
draw little or no blood, afford the best wound, upon which the 
moistened bone surfaces may be gently rubbed." (Whittaker.) 

Either animal or humanized virus, from persons previously 
vaccinated, may be used. The lymph from a vaccinated pus- 
tule, pure or in glycerine, may be kept for a long time in a her- 



VARIOLA. 135 

metically sealed tube or small phial without losing its effi- 
ciency. The crust itself is preferred by some, and may be kept 
between disinfected glass plates, carefully glued together. In 
forty-eight hours after vaccination redness and swelling oc- 
cur at the sight of the insertion, a papule forms, which develops 
into a pustule, reaching its maximum on the seventh or eighth 
day. At that time it is umbilicated and surrounded by a 
bright, red areola which enlarges for several days until it 
reaches a diameter of from two to three inches; this areola 
constitutes the sign of successful vaccination. The formation 
of pus in the vesicle is completed on about the tenth day. A crust 
gradually forms, which falls off on about the twentieth to the 
twenty-fifth day, leaving behind it a cicatrix, a circular depres- 
sion marked by dot-like depressions and radiating lines, which 
in due time becomes white; this remains for years, perhaps per- 
manently. This -process is accompanied by moderate fever, 
headache, nervous excitement, manifested by restlessness and 
sleeplessness and swelling of the axillary glands; these symp- 
toms subside promptly when incrustation begins. Usually 
they are slight in young children, but increase with advancing 
years; in persons of very nervous temperament they are often 
quite pronounced, and in scrofulous subjects untoward symp- 
toms may develop. 

It is not wise to deny that vaccination has immensely re- 
duced the number and frequency of small-pox epidemics, the 
rate of mortality, and the severity of the symptoms in the indi- 
vidual. No doubt, improved sanitary conditions and better 
modes of living among all classes have also done much in the 
same direction. The objections urged against vaccination are 
based upon the danger of introducing into the human system, 
by means of the virus, tuberculosis, syphilis, and erysipelas. 
Without attempting to call into question the force of these ob- 
jections, it is but fair to state that instances are comparatively 
very rare where this has actually occurred, and that the 
dangers from vaccination are not as great, relatively, as are 
those connected with many an operation daily made for the 
relief of evils far less threatening than an epidemic of variola. 

In case of an outbreak of small-pox, measures should be 
taken to protect the community against infection by the exer- 
cise of strict quarantine over the sick, over all suspected 



136 SPECIFIC INFECTIOUS DISEASES. 

parties, and over the locality in which the case occurs. Vacci- 
nation should be made compulsor}', and should be enforced 
without fear or favor; a person's conscientious objections to 
vaccination do not lessen the danger of his carding the infec- 
tion to others, and of thus spreading disease and death. If the 
community has no public hospital for the treatment of infec- 
tious diseases, it becomes the duty of the authorities to pro- 
vide a suitable building, decently equipped, pleasantly located, 
easy of access, yet isolated. Placards should be posted on in- 
fected houses, and every precaution taken to keep the public 
from infected localities. The patient should at once, but with 
every regard for his own comfort and safety, be taken to the 
hospital; or if that is not practicable, he must be installed in 
some room, best in the uppermost story of the house, where he 
is isolated from other occupants of the same building. The 
room must be stripped of all unnecessary furniture, and from 
the moment of its occupancy disinfection of everybody and 
everything in the room or passing from the room must be 
conscientiously practiced. Small articles which have been used 
are to be burned; clothing, bedding, towels, handkerchiefs, etc., 
are to be disinfected by the use of carbolic acid or chloride of 
lime, or mercuric chloride (see rules for disinfecting under 
t3'phoid fever). Sheets wrung out of strongly carbolized water 
may be hung up in the room, before the door, and deodorizers 
and antiseptic solutions kept in the room to render the air 
agreeable and pure. If at all possible, a room with an open 
fire-place should be used, and a moderate fire kept constantly 
burning. The linen must be changed often. The bed-covering 
should be light. The hair had better be cut short; by so doing 
"matting" will be prevented, the patient made more comfort- 
able, and decomposition of crusts avoided. Cool drinks may 
be given freely; barley-water, crust-coffee, oat-meal water, cool 
porridge, etc., may be used as the preference of the patient in- 
dicates. Milk, broths, butter milk, ice cream, any light and 
easily digested food, may be allowed; if there is angina, small 
lumps of ice may be taken into the mouth. During the fever, 
cool sponge-baths are comforting; if there is hyperpyrexia, a bath 
at a temperature of 70° may be given every three hours until 
the fever is reduced to, or below, 103°. The bath is preferable 
to medicinal antip3 r retics. The mouth and throat must be kept 



VARIOLA. 137 

clean, and injections of oil or milk and water are to be made 
into the nose if filled with dry crusts. The eyes must be care- 
fully cleansed to prevent complications already described; a 
mild antiseptic wash may be applied to the conjunctivae. In 
serious cases, if the patient is greatly exhausted, and bedsores 
or abscesses have formed, these must be watched closely and 
treated judiciously; a water-bed or the continuous warm bath 
may here be useful. Stimulants are indicated by quick and 
feeble pulse and a condition of asthenia. Tracheotomy may 
become necessary in excessive laryngeal cedema or obstruction 
of the larynx from other causes. 

During convalescence daily bathing must be kept up, carbolic 
acid soap being used liberally; the patient is not to be consid- 
ered sufficiently well to again meet others until the skin is per- 
fectly smooth and absolutely free from scabs. Even then, 
before giving him his liberty, it is wise to administer a full 
sponge bath, using a solution of corrosive sublimate (1:2000); 
this is to be washed off cautiously in a thorough warm bath, 
with carbolic acid soap. 

The prevention of pitting has always occupied the attention 
of medical men. It is well to keep crusts moistened with vase- 
line, oil, or glycerine, to prevent desiccation and the diffusion 
of flakes of the epidermis, and to relieve the intense itching. 
Ripening pustules, especially on the face, should be covered by 
a light mask of lint moistened with a medicated solution, and 
covered with oiled silk. For this purpose solutions of carbolic 
acid and of mercuric bichloride are useful. Careful emptying 
of the ripening pustule by means of a fine needle and light 
touching of the pustule with a stick of silver nitrate have also 
been recommended for the prevention of pitting. Bearing in 
mind that pitting depends wholly upon the depth to which the 
ulcerative process in each individual pustule reaches, the diffi- 
culty of the task is readily understood. Hale recommends a 
solution of peroxide of hydrogen (1:10). I have found a solu- 
tion of the aqueous extract of Hydrastis Canadensis exceed- 
ingly satisfactory; either solution should be constantly applied 
by means of the lint face-mask. Solutions of Tartar emetic 
have also been used for the same purpose, with, it is claimed, 
good results; Coste, of France, recommends boric acid solution. 
In case these moist applications are not used, either because of 



138 SPECIFIC INFECTIOUS DISEASES. 

the lightness of the attack or the establishment of convales- 
cence, it is well to use vaseline, oil, or glycerine, to prevent the 
diffusion of flakes of the epidermis and to relieve intense 
itching. 

In case of the death of the patient, common sense suggests 
the necessity of immediate and private funeral, of thorough 
disinfection of the bod}' with corrosive sublimate (1:500), and 
of every possible precaution, including thorough disinfection 
of the room and house occupied during the illness and of the 
hearse and conveyances used at the funeral. 

The attendants, including the physician, must also subject 
themselves to personal inconvenience for the sake of their own 
safet}' and that of the public. The number of nurses in attend- 
ance should be small; they must be persons well protected by 
a previous attack of the disease or by vaccination. They must 
never leave the sick room, even for a short time, without care- 
ful washing of face and hands, using carbolic acid soap freely, 
and mercuric chloride, in weak solution, on the hair. The same 
precautions are to be taken by the attending physician; since 
he is forced to come in contact with others, it is an excellent 
plan to devote one suit of clothing to visits upon smallpox 
cases, changing them each time he leaves the infected house, and 
exposing himself for a considerable length of time to the fresh 
air before visiting ether patients. A mackintosh, buttoned up 
to the chin, should be worn in the sick room. 

Therapeutics.— In the early stage of small-pox Aconite, Vera- 
trum viRiDE and Belladonna are of value. The indications 
are familiar.— Yeratrum viride covers severe pain in the back 
more fully than does Aconite, has much nausea and vomiting, 
and very great early prostration. Both have intense fever, but 
under Yeratrum the pulse is less sharp and sometimes irreg- 
ular, while under Aconite the general tension is more pro- 
nounced, with the characteristic restlessness, thirst, and gen- 
eral excitement peculiar to it. — Under Belladonna violent con- 
gestion, especially cerebral, is expressed by the throbbing 
carotids, congested eyeballs, full pulse, throbbing, bursting 
headache, and delirium. Er\ T thematous and swollen condition 
of the skin, with great itching. Tonsillitis; entire throat 
swollen and painful; difficult deglutition, especially of liquids, 
which return through the nose. Hard, "breaking" backache. 



VARIOLA. 139 

Useful also in the last stage, with thread-like pulse, titter ex- 
haustion, jerking of bed-clothes, frequent starting during sleep, 
purplish condition of the surface, bad throat with foul odor 
from the mouth, trembling tongue, stupor.— Apium virus in 
some respects resembles Belladonna, especially in 'its close re- 
lation to the skin-symptoms; it also covers in a striking manner 
the oedematous condition which may become an important 
complication, and bears a close relation to the kidney. Sting- 
ing, burning pains are felt in the skin and throat; there is con- 
siderable fever, with chilliness from slight motion or exposure; 
albuminuria; dyspnoea. May be called for in ovaritis as a 
sequel of small-pox. 

During the stage of eruption and suppuration, Vaccininum, 
Yariolinum, Melandrinum, Antimonium tartaricum, Hepar 
sulph., Hydrastis, and Mercurius are indicated. 

Vaccininum, the attenuated lymph from the cow-pox 
vesicle, Variolinum, the attenuated lymph from the small-pox, 
and Melandrinum, the attenuated lymph from the horse-pox 
vesicle, are isopathic remedies, and as such many practitioners 
are prejudiced against their use. Personal experiences with 
them, at least with Variolinum, and the testimony of reliable 
and unbiased observers, have demonstrated the power of these 
preparations, if given in time, to greatly modify the results of 
exposure and often to insure complete protection and to so 
modify the suppurative process that the secondary fever and 
other concomitants of this stage are comparatively light, the 
eruption itself proceeding kindly through the various stages of 
its development. I have used Variolinum in the 6th and 12th 
dec. trit., and consider it a most useful remedy. — Antimonium 
Tartaricum is indicated when the eruption is tardy in "coming 
out," resulting in severe constitutional disturbances which 
point to the remedy. There is: great weakness, with much 
restlessness ; white, pasty coating of the tongue ; constant 
nausea, rendering the patient very uncomfortable; coolness of 
the surface, with bluish appearance; rattling in the throat and 
chest, with difficulty of breathing. In cases where the respira- 
tory organs are involved in the beginning (dry tearing cough), 
or later, when typhoid symptoms exist. Should not be used 
higher than the 3d dec. trituration.— Hepar sulphur, is espe- 
cially useful in scrofulous persons, given to swelling of the 



140 SPECIFIC INFECTIOUS DISEASES. 

glands, in whom a slight scratch or tear of the skin induces a 
slowly healing sore. The presence of sore throat, with stitch- 
ing pain, when swallowing, from ear to ear, and hoarse, 
croupy cough, are characteristics. It has proved very useful in 
the cases where during and after convalescence boils and other 
skin affections harass the patient.— Hydrastis Canadensis has 
proved of service because of its beneficial action upon the ulcer- 
ative process; clinical experience has shown that it favors 
kindly healing in the individual pustule, thus preventing pit- 
ting. In fact, provers of the drug have suffered from pustules 
quite like those of smallpox in appearance and development. 
There is much swelling, redness and itching of the skin; the 
mouth and throat are very sore and covered with pustules; in- 
tense aching in the small of the back; faintness and prostra- 
tion; sensation of great weakness in the legs.— Mercuries is 
indicated when the sore throat with copious salivation, 
swollen, flabby tongue which takes the imprint of the teeth, 
and characteristic intestinal symptoms are marked. 

When the case progresses unfavorably and the hemorrhagic 
tendency shows itself, Arsenicum becomes an important rem- 
edy. The general condition resembles that described under 
typhoid fever; the asthenia is well pronounced; the pustules 
lose their roundness, sink in, become flat on top, and, with 
their areola?, grow livid, dusky; haemorrhage into the pustules. 
Petechia?. Diarrhoea.— Lachesis and Crotalus are important 
remedies, the latter especially. Great prostration; severity of 
constitutional S3 r mptoms, of a typhoid character; passive 
haemorrhages from the orifice and into the mucou# surfaces; 
scantiness and dark color of the urine; tormenting thirst; mut- 
tering delirium; coldness of the surface and extremities.— Am- 
monium carbonicum. "Hcemorrhagic diathesis from fluidity' of 
blood and dissolution of red blood-corpuscles, tendency to gan- 
grenous ulcerations, high-graded adynamia." Lilienthal. — Am- 
monium muriaticum "Eruption well developed upon trunk and 
upper extremities, but scanty on the lower; sore throat, with 
swelling about neck; haemorrhages." Ibid. 

Of other remedies, Cimicifuga has been highly lauded by 
writers for the relief it affords from the intense muscular pains 
and soreness which often it is so hard to bear, and, like Sarra- 
cenia, has been credited with the power of favorably modifying 



VARICELLA. 141 

the disease so as to shorten its course and to prevent pitting. 
Phosphorus, Bryonia or Kali bichromicum may be indicated 
by respiratory symptoms present. Muriatic acid, Phosphor- 
ic acid and Rhus toxicodendron in typhoid states. Cam- 
phora in unexpected retrocession of the eruption and symp- 
toms of collapse. 



VARICELLA. 

Varicella, also called Chicken-pox and Spurious or False Pox, 
is an acute infectious disease which usually occurs as an epi- 
demic, but sometimes is sporadic. It is peculiar to childhood 
from the second to the tenth year; susceptibility to it grows 
less after the sixth year, and practically ceases with the tenth 
or twelfth year. Its most striking feature is the characteristic 
eruption. Hebra and his followers maintain the identity of 
varicella with variola. Inability to produce either disease by 
inoculation with virus from the other, and the fact that an 
attack of one disease does not give immunity from the other, 
seem to disprove this claim. The stage of incubation lasts 
from ten to fifteen days. 

Symptomatology. — In many cases the eruption appears with- 
out prodromata or constitutional disturbance. It consists 
of numerous discrete, raised, red papules which within a few 
hours assume a vesicular form, as large as a pea, or larger, and 
which in exceptional cases may even have a diameter of half 
an inch to an inch. These vesicles are irregular in outline, su- 
perficial, not umbilicated, save on the face, where a depression 
on the top of the vesicle is often noted. Only in exceptional 
cases is the rete Malpighii involved. The skin surrounding the 
vesicles is not infiltrated or hyperaemic. The contents of the 
vesicle become purulent within thirty-six to forty-eight hours, 
after which it shrivels, and a dark -brown crust forms. This 
falls off in three or four days, rarely leaving a scar, save in 
some cases on the face. Several fresh crops of vesicles may 
follow each other, showing the eruption in different stages of 
development at the same time. 

The rash is first seen on the trunk (waist and chest), then 



142 SPECIFIC INFECTIOUS DISEASES. 

on the face, forehead and hairy scalp; it is usually abundant, 
and a hundred, or more, vesicles may be counted at a time. 

Often no constitutional disturbances arise, the patient being 
able to be about the room throughout the illness ; others, as 
prodromata, have slight fever, or light chill followed by fever, 
with general malaise, anorexia, vomiting, and aching in the 
back and legs. The temperature may reach a maximum of 
102°; if the fever is high, it does not yield with the appearance 
of the eruption, but continues until the latter fades. In excep- 
tionally severe cases convulsions may occur. 

Course and P< ognosis. — The course of the disease is toward 
rapid and complete recovery, without serious complications. 
At times the itching is great, and the patient, especially if 
scrofulous, may by violent scratching cause ulceration of the 
broken surfaces, with much pain and subsequent scarring. In 
others the hemorrhagic tendency may be pronounced and com- 
plicate the case. Some observers (Hutchinson, Eustace 
Smith) describe a form which occurs in weakly, badly nour- 
ished, cachectic children, in which necrosis extends deep into the 
muscular tissues with, often, involvement of the eye and possi- 
ble loss of vision; these cases tend to a fatal termination. Mild 
nephritis and infantile hemiplegia are possible sequels. 

Diagnosis.— If seen early, diagnosis is easy; if seen late, or 
the symptoms are exceptionally severe, it may be mistaken for 
smallpox. The diagnosis of varicella depends upon the isolated 
character of the eruption; its superficial nature; the absence, 
save at times on the face, of umbilication; absence of areolae 
and general hyperemia of the skin; absence of secondary fever 
and of amelioration of the fever from appearance of the erup- 
tion; mild character of constitutional symptoms. 

Treatment. — As to general management, little is required be- 
yond the exercise of common sense. It is prudent to keep the 
patient in bed; the diet should be light and nourishing; the 
face, to prevent scratching and scarring, should be covered 
with a light layer of lint, moistened with some soothing lotion. 
As to remedies, Antimonium tart., Mercury, Pulsatilla, 
Gelsemium, Belladonna, Thuja, and others, may be indi- 
cated. 



EPIDEMIC INFLUENZA. 143 



EPIDEMIC INFLUENZA. 

Synonyms: La Grippe.— The Grip. — Russian (or Chinese, 
Spanish, etc.) Catarrh or Fever.— Epidemic 
Catarrhal Fever. 

An acute, infectious fever, characterized by early and pro- 
found prostration of the vital forces, quite out of proportion 
to the fever existing, with symptoms of severe catarrhal in- 
volvement of the respiratory and gastro-intestinal mucous 
membrane, marked disturbance of the nervous system, and ten- 
dency to complications and sequelae which in seriousness over- 
shadow the original disease. 

The disease has been known from early times, and can be 
clearly traced back to, at least, the twelfth century; on the 
American continent it first appeared in Massachusetts and 
Connecticut, in 1627; the last severe epidemic, 1889 to '90, 
swept over the entire country, and reappeared during the two 
following seasons. It is first sporadic, then becomes epidemic 
and practically pandemic, over-whelming entire countries and 
continents with startling rapidity. 

Etiology.— Pfeiffer, of Berlin, in 1892, discovered in the pus- 
cells of tracheal mucus the micro-organisms which are peculiar 
to epidemic influenza. It has been pretty conclusively shown 
that their presence is limited to this disease, that numerically 
they increase and decrease -with the rise and fall of the influ- 
enza, that they disappear with the cessation of the fever and 
the disease, and that by inoculation with them the influenza 
may be reproduced. These micro-organisms are of the breadth 
and one-half the length of the septicaemia bacillus; they occur 
in immobile, hanging drops which never coalesce (Kitasato). 
Of late they have been found in the blood (Canon). 

The conditions upon which depends an outbreak of the dis- 
ease are wholly unknown. It is quite likely that the infectious 
principle is carried by the air, and is thus brought in contact 
with the respiratory mucous membrane. That this infectious 
principle is exceedingly virulent is amply proved by the fact 
that no age, sex, race or condition seems exempt from its 



144 SPECIFIC INFECTIOUS DISEASES. 

action. It is reasonable to presume that sporadic cases occur; 
but the disease soon becomes epidemic, following the lines of 
travel and spreading over vast territories in an incredibly short 
period of time. It is still an open question tc what extent in- 
fluenza is contagious; that it can be carried in clothing, 
fomites, etc., is generally admitted. Predisposing causes can 
hardly be said to exist save that bodily weakness, by lessening 
the powers of resistance, may here, as elsewhere, come under 
this head. But men and women, old and young, alike fall easy 
victims to this swiftly moving and intensely active agent; chil- 
dren of less than one year of age, it is claimed, are somewhat 
exempt, yet cases are on record of sucklings only a few days 
old, dying with unmistakable symptoms of the epidemic. Local 
conditions, character of soil, etc., seem to have no bearing upon 
the aetiology of the affection; in fact, the high seas are not ex- 
empt from its ravages, as is shown from the experience of ves- 
sels that were obliged to put back to port because the crew, 
well when shipping, were disabled from work by a violent at- 
tack and rendered helpless by this disease. 

Symptomatology. — The onset of the disease, in a great ma- 
jority of cases, is quite sudden. A moderate chill is followed by 
active fever and symptoms of catarrhal involvement, with, at 
first, dryness and swelling of the mucous membrane, which 
later secretes abundantly. There is great prostration, quite as 
noticeable in the strong and robust as in the feeble, and 
markedly affecting the circulatory apparatus, giving rise to a 
quick, weak pulse. Severe headache, with pain in the eyes, 
worse from motion; sore, bruised, beaten feeling all over, with 
heavy aching and pain in the extremities, loins, and back; these 
pains are persistent and hard, and the severity of the backache 
here is greater than in any acute disease saA r e dengue and small- 
pox. The temperature in the average case runs from 101° to 
103°; it rises and falls in proportion to the severity of accom- 
panying constitutional symptoms. In light cases slight evening 
exacerbations are noted, while in severe cases the temperature 
rises quickly and remains at its maximum for a period ranging 
usually from four to seven days. The fever, in the milder type, 
terminates by crisis; in the more serious cases, by lysis. 

The prominence of certain groups cf local symptoms con- 
stantly modifies the picture here presented. Thus, often, and 



EPIDEMIC INFLUENZA. 145 

especially in children, symptoms of gastro-intestinal catarrhal 
irritation are well pronounced, and then nausea and vomiting 
are present from the beginning of the disease. The tongue is 
flabby, thickly coated, and shows the indentations of the teeth; 
there is loss of appetite; vomiting and diarrhoea may become 
so persistent and exhausting as to resemble a severe attack of 
cholera infantum. Particularly inyoung children symptoms of 
collapse appear, with sunken eyes, depressed fontanelles, great 
restlessness, and death. In exceptional cases there is constipa- 
tion. 

Again, the nervous symptoms may be prominent and severe 
headache, with symptoms of meningeal irritation, be present; 
the latter symptoms are often seen in cases of influenza-pneu- 
monia. In this type of the disease the rheumatoid pains in the 
back, loins and extremities are especially severe, accompanied 
by a sense of great weakness in the affected parts, without ap- 
preciable swelling. Not infrequently the prostration becomes 
so pronounced that the general condition closely resembles the 
typhoid state. .Drowsiness, at times strikingly persistent, has 
been noted. Earl (Starr's American Text-book of Diseases of 
Children) mentions irritability and fretfulness as commonly 
present in children who suffer from this type of influenza, and 
he emphasizes the occasional occurrence "of an obstinacy 
which is truly remarkable; they sometimes resist the slightest 
touch, and refuse all examination on part of the physician." 
Convulsions may occur, but are infrequent. 

Much oftener, however, does the brunt of the disease fall 
upon the respiratory mucous membrane. A general catarrh of 
the respiratory organs may develop rapidly, with redness and 
suffusion of the eyes, catarrh of the middle ear, and painful 
paroxysms of cough, accompanied by oppressed breathing, ex- 
pectoration of scanty and tenacious mucus, and sharp lanci- 
nating pains in the chest, particularly in the substernal region. 
Slight fever, with moist, yellowish coated tongue, considerable 
thirst, headache, sleeplessness, great exhaustion, cardiac weak- 
ness, and profuse sweating are the accompanying constitutional 
symptoms. The general capillary bronchitis thus developing 
is always bilateral; pneumonia frequently complicates it, either 
from the very beginning of the chest-trouble, or it develops in- 
sidiously during the progress of the disease, or makes its ap- 
10 



146 SPBCIFIC INFECTIOUS DISEASES. 

pearance suddenly, and usually unexpectedly, during a seem- 
ingly satisfactory convalescence, often in light cases. 

The prominence of these local symptoms has given rise to a 
classification of the various types of influenza, and writers rec- 
ognize a thoracic, gastro-intestinal, nervous or typhoid form 
of the disease; in many cases, however, a strict classification 
is found impracticable because the symptoms shade from one 
form into the other. 

Recovery is often tardy, and frequent relapses are common. 

Complications and Sequelae.— The complications which may 
arise during an attack of influenza are numerous and serious; 
among these, affections of the respiratory organs are conspicu- 
ous. Bronchitis, involving the large bronchi or extending into 
the small ramifications, is common; it is very dangerous to 
old people and to persons already exhausted from previous ill 
health; there is a tendency to pulmonary oedema, heart failure, 
or progressive cyanosis; broncho-pneumonia also may result. 

Pneumonia, catarrhal or croupous, occurs, and during the last 
epidemic, from 1889 to '92, it greatly increased the death-rate. 
In some cases the symptoms of acute, violent infection are at 
first most pronounced, accompanied with high fever and very 
pronounced dyspnoea, the signs of pneumonia declaring them- 
selves in three or four days, usually with slight cough and scanty 
expectoration. In other cases the pneumonia seems due to the 
profound depression of the nervous system; this applies espe- 
cially to the form observed in the aged and in feeble persons or 
young children. It is safe to state that the tendency to pneu- 
monia is well pronounced, and many cases have been put on 
record which show that very slight exposure in persons but 
little inconvenienced, on account of the mildness of the attack 
of influenza, proved sufficient to cause fatal pneumonia. Pep- 
per found pneumonia in 4 per cent, of the 35,413 cases collected 
by him, with a mortality of 11.65 per cent.; many of these 
were characterized by great feebleness of the respiratory mur- 
mur, typhoid tendency, cardiac weakness, involvement of both 
lungs, intense abdominal engorgement, with jaundice and 
slight intestinal haemorrhage. The serious character of the pul- 
monary affection is also shown by the frequency with which 
plastic pleurisy, empyema, purulent pericarditis and, indirectly, 
pulmonary phthisis result. The latter, as in the case of albu- 



EPIDEMIC INFLUENZA. 147 

minuria, depends upon an existing latent tendency, and yields a 
high rate of mortality. Important complications affect the 
nervous system. A pseud o-cerebro-spinal meningitis, closely 
resembling the true spotted fever, and differentiated from it 
chiefly by the absence of petechias, has been described; it may 
prove fatal from the severity of the acute symptoms or, in the 
subacute form, from exudation and resulting pressure. Per- 
ipheral neuritis, with atrophy and partial paralysis, neural- 
gia, insanity, and abscess of the brain, occur less often. 

When it is borne in mind that influenza, by the remarkable 
depression of the nervous system which constitutes one of its 
most striking features, is likely to develop any latent tendency 
to morbid action, it is readily understood that the sequels of 
this disease must be exceedingly varied; thus, in addition to 
those already described, we find various affections of the eye 
(as keratitis), diseases of the ear (as purulent otitis media), 
nephritis (usually mild), numerous affections of the skin 
(herpes labialis, urticaria, roseola, furuncles which may prove 
both painful and persistent), chronic intestinal catarrh, gland- 
ular swellings with suppuration, dropsical conditions, rheuma- 
tism, chorea, etc. In fact, the list of these sequelae is constantly 
increasing as the disease is more thoroughly studied and the 
results of individual experience compared and tabulated. 

Diagnosis. — In the presence of an epidemic, and in the ordi- 
nary form of the disease, a correct diagnosis is easily made. 
The suddenness of the attack; the myalgic pains, especially in 
the loins and back; the marked character of the catarrhal 
symptoms, with the absence of the usual causes of bronchitis; 
the profound prostration, quite out of proportion to the height 
of the fever, these are usually sufficient to establish the diag- 
nosis. 

Cerebrospinal meningitis closely resembles certain cases of 
influenza, and a positive diagnosis may be difficult or impossi- 
ble. In influenza the absence of the petechial eruption and the 
presence of catarrhal symptoms must be duly considered; there 
is also less rigidity of the muscles than in spotted fever; but 
often the resemblance is so close that a bacteriological exami- 
nation alone can positively determine the nature of the dis- 
ease. From typhoid fever: the early predominance of catar- 
rhal symptoms, the suddenness of the onset, the absence of 



148 SPECIFIC INFECTIOUS DISEASES. 

the characteristic eruption, of abdominal tenderness and of 
splenic enlargement; the irregularity of the fever, in such sharp 
contrast to that of typhoid, are usually sufficient to differen- 
tiate even in those cases which by their tendency to a "low" 
state, haggard countenance, intestinal catarrh, etc., suggest a 
continued or typhoid fever. The diagnosis from simple 
catarrh should present no difficulty save in exceptionally light 
cases; prudence suggests that during the prevalence of an epi- 
demic all patients presenting symptoms which point to "La 
Grippe" should be kept under close observation. 

Prognosis.— The seriousness of a case of influenza is measured 
by the gravity of existing complications. Uncomplicated, and 
in a person of average vigor, its death rate is but a small frac- 
tion of one per cent., from one-fourth to one-half of one per 
cent. In those enfeebled by old age or by some previously ex- 
isting malady, a guarded prognosis is to be given. The exist- 
ence of pulmonary, cardiac, or renal disease, of chronic nervous 
affections, or a lack of normal vitality, greatly predispose to 
an unfavorable issue; the occurrence of grave complications, 
such as pneumonia, always gives to the case a serious aspect. 
Again, even though recovery may take place, the sequels, such 
as pulmonary phthisis, are to be dreaded. As stated, the dis- 
ease has a tendency to favor the development of affections 
which may have lain dormant for years, and it thus greatly 
and unfavorably affects the rate of mortality in a community 
during and after the visitation of an epidemic. 

Treatment.— No means of prevention are known. Gold- 
schmidt and Althaus advise re vaccination with animal lymph, 
but their recommendation is not based upon grounds that com- 
mend it to the profession. In view of the universal liability to 
the infection, good sense suggests that during the prevalence of 
an epidemic especial care should be had to avoid taking cold 
and to husband physical energy. Hence, exposure to draughts 
or wet, carelessness in clothing, sudden checking of perspira- 
tion, excesses of any kind, overwork, in fact, anything that 
taxes the vital forces, should be scrupulously avoided. 

Once ill, complete rest in bed until the patient has become 
fully convalescent is of the utmost importance; neglect of this 
rule has proved disastrous in many cases. The temperature of 
the sick room is to be kept even and moderate, and draughts 
are to be carefullv excluded. 



EPIDEMIC INFLUENZA. 149 

Cheerfulness of surroundings, diligence in guarding against 
danger of taking cold and in avoiding all useless waste of en- 
ergy, a supporting diet, and an abundance of sleep consti- 
tute the most important features of general treatment. Pur- 
gatives, opiates, and routine antipyretics are to be avoided 
as useless and even dangerous. Phenacetine, in doses of three 
to five grains, repeated two or three times in the twenty-four 
hours, is said to reduce the temperature, relieve pain, and af- 
ford sleep. The authorities of the dominant school commend 
its use, and E. M. Hale speaks highly of it; I have no experi- 
ence with it. Whittaker states that Salipyrin, 10 to 15 grs. 
every two to four hours, is almost a specific. 

During convalescence, care must be taken to avoid exposure 
and subsequent relapse. Freedom from anxiety and worry, 
and a complete change of surroundings, with protracted resi- 
dence in a mild, even climate, will be found highly beneficial. 
At almost any period the moderate use of stimulants may be- 
come a necessity; if so, champagne will prove especially grate- 
ful and helpful to old people and children. 

Therapeutics.— Aconite. The catarrhal fever is high and 
presents the characteristic restlessness, thirst, full and quick, 
hard pulse-beat, hot skin, glowing face, etc., of the remedy. 
Dryness and irritation of the upper air-passages; hoarseness, 
dry cough.— Gelsemium has proved one of our best remedies 
in the uncomplicated form. It has shivering, fever, great 
weariness and depression, extreme languor. Heat in the head, 
with watery discharge from the nose, sneezing, dull headache, 
dizziness, rawness and burning in the larynx. Considerable 
aching all over; at times myalgic pains are very severe; so 
"used up" that he feels sure a long and serious illness is upon 
him. The remedy has done its best work for me when given 
in fractional doses of the mother tincture, every one or two 
hours.— Eupatorium perfoliatum. The catarrhal symptoms 
are overshadowed by the severity of the pains in the extremities 
and back, which are of a "bone- breaking" character. Nausea, 
biliousness, vomiting of bile. Weak pulse; great prostration. — 
Arsenicum iodatum. The catarrhal symptoms are intense, 
affecting especially the eyes, nose and throat. Discharges 
acrid, irritating. Shivering; hot, dry skin. Great prostration, 
so that even a slight exertion is followed by complete exhaus- 



150 SPECIFIC INFECTIOUS DISEASES. 

tion. Characteristic restlessness and thirst. Desire for artificial 
warmth. Presentiment of a fatal issue of the illness. Later, 
great difficulty of breathing, with coldness, cold sweating, fa- 
tiguing, shaking cough; expectoration of tough, viscid sputum. 
Suited to enfeebled, old people. — Sanguinaria. Fluent coryza, 
with dryness and heat in the throat, burning in the pharynx 
and oesophagus. — Allium cepa. Profuse discharge from eyes 
and nose; soreness and dryness of the throat; supra-orbital and 
occipital headache of dull, pressing character; dry, racking 
cough. — Kali bichromicum. Fluent coryza, acrid, excoriating; 
heat and dryness of the eyes ; pharyngeal involvement, dark 
red, puffy, with cough, accompanied with pain from the mid- 
sternum to the back, and expectoration of tough, stringy 
mucus. — Mercury. Catarrhal symptoms very persistent; in- 
volvement of the middle ear; shiverings, alternating with 
flashes of heat; copious sweatings at night; discharges are 
muco-purulent; nose excoriated; eye-lids sore. 

In case severe complications in the form of bronchitis or pneu- 
monia develop, the remedies indicated under these headings 
must be exhibited. Bryonia, Phosphorus and Tartar emetic 
are especially useful.— Bryonia: Bronchitis; tickling in the 
throat; explosive, tearing cough as if the chest and head would 
fly to pieces; great prostration; sharp, cutting, pleuritic pains. 
— Phosphorus. Great weakness and prostration; broncho- 
pneumonia; hoarseness; dry, tearing cough; oppression in the 
chest.— Tartar emetic. Great depression. Tendency to short 
periods of nausea and faintness. Dyspnoea, hoarseness, shiv- 
ering, fever and sweating at irregular intervals. Later, large 
mucous rales; moist, loose cough, with much rattling of mu- 
cus in the throat and bronchi, but comparatively scanty expec- 
toration. 

When myalgic pains are marked, or the patient complains of 
"rheumatism," Act.ea, Cimicifuga, Bryonia or Rhus toxico- 
dendron, indicated by their characteristic symptoms, fre- 
quently relieve. Phytolacca, also, is useful when the lumbar 
region is particularly painful and when the pain is streaking 
up and down the spine. Hale recommends Manaca when there 
is a sensation in the head and joints "as if bound tightly by an 
iron band;" he adds a teaspoonful to a glass of water, giving a 
teaspoonful of the solution every half hour. 



epidemic parotitis. 151 

Pulsatilla, Chelidonium, Mercurius, Antimonium crudum 
are indicated when gastric or bilious symptoms are pro- 
nounced. Special irritation of the nervous system may suggest 
Cimicieuga, Belladonna, Hyoscyamus, Stramonium, Opium, 
Bryonia, Baptisia. 

Gisevius, of Berlin, recapitulating the experiences gathered 
during the epidemics of 1889 to '90 and 1890 to '91, speaks 
highly of China lx, which he used for very great weakness and 
exhausting sweats. The patients resemble those who are re- 
covering from a severe attack of illness; are in a state of great 
mental and physical depression. Vertigo and fainting, aggra- 
vated on leaving the bed. Sleep does not refresh; pulse weak 
and small; heart-beat feeble; substernal irritation. Larger 
bronchi filled with accumulation of mucus; anorexia, with 
bitter, • insipid taste. Occasionally diarrhoea. "All writers 
admit the tediousness of this stage, which rapidly disappears 
under China, every two or three hours." 



EPIDEMIC PAROTITIS.— MUMPS. 

Definition and Causation. — An acute infectious disease, char- 
acterized by inflammation and enlargement of the parotid 
glands, with tendency to involve the testes in males and the 
breasts, rarely the ovaries, in females. It is both endemic and 
epidemic, more often the latter. If endemic, it is usually so in 
large cities and prevails in certain restricted localities, as 
boarding schools, institutions or barracks; under such condi- 
tions it may become epidemic, ninety per cent, of the inmates 
of such places having been known to have the disease. Epi- 
demics usually occur in the colder seasons of the year. No age 
or sex is exempt; but men are more liable to the disease than 
women, and the very young and quite old are rarely attacked. 
The disease is contagious, spreading from patient to patient; 
contamination of the atmosphere through expectorated matter 
spreads the contagion. Probably mumps originates in the 
mouth and the micro-organism which constitutes the essential 
factor is conveyed to the parotid gland through Steno's duct; 
the frequency of stomatitis or some form of sore mouth or 
throat in connection with parotitis gives an air of strong prob- 



152 SPECIFIC INFECTIOUS DISEASES. 

ability to this theory, which is further strengthened by the im- 
munity of infancy and old age, Steno's duct in the former being 
too small, and in the latter too atrophied, to permit the en- 
trance of noxious matter. (Soltman.) The age of preference 
is from two to ten years; among adults, soldiers furnish the 
larger number of sufferers. One attack confers immunity from 
others. 

Symptoms. — The period of incubation covers from fourteen 
to twenty-one days and it is not characterized by any symp- 
toms. The period of invasion is marked by shivering or chill, 
followed by moderate fever, the thermometer ranging from 
100° to 101°, and only rarely from 102° to 104°. Malaise, 
headache and slight gastric derangement are often, but not 
always, present. Pain at the angle of the jaw, of varying de- 
grees of intensity, gives warning of the development of the 
local affection, and soon a swelling a little below and in front 
of the ear, at first slight, but rapidly increasing, makes its ap- 
pearance. This enlargement is one-sided and progresses so 
rapidly that within thirty-six to forty-eight hours it has 
passed forward in front of the ear and below it, extending 
down the neck, pushing the lobe of the ear upward, involving 
the entire side of the face, cheek and neck, and obliterating the 
natural outlines of the parts; occasionally it extends through 
all the tissues of the throat, and very commonly pushes the 
head to one side. While sometimes severe pain is experienced, 
in the larger number of cases suffering results chiefly from the 
feeling of tightness and tension in the parts and from the im- 
possibility of opening the mouth for purposes of speech, drink- 
ing or eating. Every attempt to do so produces extreme dis- 
comfort, and gives rise to distortions of the face which to the 
beholder are extremely comical. In some cases, within two or 
three days from the appearance of the swelling, the other side 
of the face becomes involved and passes through the same pro- 
cess. The swelling itself is of a "doughy" consistency, though 
hard and firm if the enlargement is extreme. 

The constitutional disturbances accompanying the swelling 
are usually slight. Stomatitis, with foulness of breath, is 
often present. At first the salivary secretion is quite scanty; 
later it becomes copious, and may thus prove a source of much 
annoyance to the patient. Earache, with hardness of hearing, 



EPIDEMIC PAROTITIS. 153 

is also often noted. In the great majority of cases the disease 
runs a mild course, the enlargement subsides after seven or ten 
days, food and drink can again be taken, and recovery takes 
place rapidly, with almost assured immunity from relapse. 

Exceptionally the symptoms are severe, and there is from an 
early stage not only high fever, but delirium and such marked 
prostration of the nervous system as to give rise to a well- 
pronounced "typhoid" type. 

A tendency to inflammation of the testicle constitutes a strik- 
ing feature of mumps. Orchitis may occur at any time, but 
more frequently appears after the intensity of morbid action in 
the parotid has exhausted itself. It is commonly unilateral, 
with a preference for the right side; it varies in severity, effu- 
sion occasionally extending into .the tunica vaginalis; it is 
characterized by swelling and tenderness in the gland, sensa- 
tion of weight and pain, the latter extending along the cord, 
and frequently vomiting and fever. Orchitis with mumps is 
rarely seen prior to puberty; it generally continues for three 
to five days, and then gradually passes away. In bad cases 
atrophy of the testicle may result. 

If parotitis is double, the right testicle usually is affected; if 
unilateral, there is a preference for the testicle on the affected 
side; double orchitis is rare. In females, vulvo-vaginitis and 
a moderate mastitis take the place of orchitis in the male. 

Complications. — In exceptional cases there is from the start 
very high fever, scon followed by delirium and symptoms indi- 
cating meningitis; the prognosis in these cases is serious; in a 
large proportion of the fatal cases, examination after death 
has shown the existence of meningitis. 

Very occasionally acute mania and insanity have been ob- 
served. Arthritis, albuminuria, acute uraemia, and many com- 
plications so rare as to possess little, if any, practical interest 
to the practitioner, have been put on record. Some cases are 
followed by permanent deafness; others by certain affections 
of the eye, as amblyopia, stenosis of the lachrymal glands and 
conjunctivitis. 

Suppuration of the parotid glands is fortunately very rare. 

Secondary Parotitis. — It is proper here to call attention to 
the existence of a secondary or metastatic parotitis which may 
occur as a complication of any serious acute disease, such as 



154 SPECIFIC INFECTIOUS DISEASES. 

typhoid fever, typhus, phthisis, carcinoma, or injury to the ab- 
dominal or pelvic organs. Its symptoms are those of epidemic 
parotitis, save that the swelling is much greater and that 
there is pronounced tendency to suppuration. If suppuration 
takes place, the discharge is outward or into the external audi- 
tory meatus. Extensive sloughing and gangrene are common 
here, and such permanent injury as facial paralysis and deaf- 
ness may result. 

Diagnosis. — The rare occurrence of inflammation of the par- 
otid gland, save in mumps, almost establishes the diagnosis in 
young patients. In older persons the nature of the swelling 
is such as to prevent difficulty in recognizing the cause. Retro- 
pharyngeal abscess would give rise to similar difficulty in open- 
ing the mouth, of swallowing, etc., but the appearance of the 
face and a digital examination would establish the diagnosis. 
An extensive lymphangitis might create doubt, but its location 
on the neck, the tediousness of its course, and its tendency to 
suppuration would determine the nature of the affection. 

The Prognosis of non-complicated mumps is good. 

Treatment. — The precaution of keeping the patient in bed is 
always justified; it is rendered doubly necessary when compli- 
cations in the way of testicular, mammary, or ovarian involve- 
ment are threatening. Owing to the difficulty of swallowing, 
the diet will be wholly liquid, with a preference for milk; 
later, especially if anaemia threatens, more stimulating food 
must be used, and cod-liver oil, clear or in some combination, 
is indicated. 

It is well to protect the swelling itself with cotton wool, 
covered with oiled silk. The use of an ointment containing 
fluid extract of Belladonna in vaseline or of a Belladonna 
glycerole is unobjectionable. If the swelling prove tedious, the 
local use of the tincture of Iodine or of Iodoform collodion 
(1:15) will prove serviceable. Of suppuration, there is practi- 
cally no danger in the epidemic form. In the secondary form, 
or whenever danger of suppuration exists, poultices (flax-seed, 
bread and milk) may be employed as indicated, and as soon as 
fluctuation can be detected an incision must be made parallel 
to the line of important vessels and nerves, to avoid doing in- 
jury to these. 

In orchitis, leeching (four to six leeches applied to the inner 



EPIDEMIC PAROTITIS. 155 

border of the groin) has been recommended; absolute rest and 
support of the testicle by suspensory bandage are indispen- 
sable; in case of vulvo-vaginitis, use the hot douche; the in- 
flamed mammae may require the local use of Belladonna oint- 
ment or glycerole and protection from the air by light com- 
presses of cotton wool covered with oiled silk. If meningitis 
occurs, it must be treated according to its indications. (See 
chapter on Meningitis.) 

Therapeutics. — Aconite, when the fever is high and charac- 
teristic thirst and restlessness are present. Of service only in 
the stage of invasion.— Belladonna: The swelling is bright- 
red, radiating from the centre. Right-sided. Great heat of the 
body, particularly in the inflamed part. Sharp, stitching 
pains, or pain gradually increasing until it becomes unbearable, 
then stops, and reappears in the same manner. Dryness of the 
mouth. Tongue white, with red edges. Pulse full, hard. Cere- 
bral congestion and symptoms of meningeal irritation or in- 
flammation.— Pulsatilla: Chilliness, fever without thirst; 
intolerance of pain; pain now here, now there; swelling pale; 
cannot bear the close room. Thickly coated tongue, with dry- 
ness of the mouth and bad taste. Mammary involvement. — 
Rhus toxicodendron. Swelling on the left side, dark-red; great 
restlessness; typhoid symptoms. — Lachesis: Extension of the 
swelling from right to left; swelling hard, bluish, mottled; 
great depression; hardness of hearing; cannot bear the slightest 
touch about the throat or the inflamed gland; flushes of heat; 
sharp, lancinating pains in the inflamed gland, which changes 
to a burning pain when touched. Patient feels worst when 
awaking from sleep.— Mercurtos iodatus. Flabby tongue, 
showing indentation of the teeth; offensive breath from 
stomatitis; fever with alternating hot and cold spells; frequent 
copious sweating, especially at night, without relief of symp- 
toms; salivation copious and stringy. — Conium: Swelling very 
hard; mammary and ovarian involvement; there is little pain 
in the enlarged gland, or it is of a darting character. 

Bromine is recommended when the discharge is excoriat- 
ing; there is much heat in the gland, and marked hardness 
around the fistulous opening; scrofulous diathesis. 

Consult also: Lycopodium, Bryonia, Carbo veget., Coccu- 
lus, Phytolacca, Calcarea. When orchitis exists, Aurum, 



156 SPECIFIC INFECTIOUS DISEASES. 

Pulsatilla, Arnica, Conium, and other remedies mentioned 
under appropriate headings will be in place. 

In case there is suppuration, Hepar sulphur, and Aurum 
will prove useful. 



WHOOPING-COUGH. 

( Pertussis. — Tussis con vulsiva . ) 

General Definition and Causation. — Whooping cough is an 
acute infectious disease especially affecting the respiratory mu- 
cous membrane and giving rise to paroxysms of convulsive 
cough characterized by a long-drawn inspiratory effect during 
which the "whoop" is produced. It is epidemic, but sporadic 
cases occur; it appears chiefly in winter and spring. It is essen- 
tially a disease of childhood, preferably attacking children from 
six months to six years; after the tenth year, very slight sus- 
ceptibility exists; yet, adults and old people may have it. In 
adults the attacks are usually light, save in the very aged, in 
whom the occurrence of the disease is quite rare, but dangerous, 
owing to their low powers of endurance. Females are some- 
what oftener attacked than males (5 to 4), and suffer more se- 
verely. Anaemic children, or children who are subject to bron- 
chial or nasal catarrh, or who have just recovered from mea- 
sles, are particularly liable to the infection. According to the 
U. S. Census Report, the fatality- of the disease is twice as 
great among the negroes as it is among the whites. One at- 
tack almost positively protects against future ill-effects from 
exposure. 

The contagious element of tussis is probably contained in 
the sputum, and through its agency the disease is directly con- 
veyed from person to person. The theory of the neurotic 
character of whooping cough has been generally abandoned, 
the presence of the marked nervous symptoms being explained 
upon the hypothesis that "pertussis is a mycosis whose toxines 
have a special action upon that part of the nervous system 
which presides over cough, — to wit, the centres of the superior 
laryngeal and vagus nerves." (Whittaker.) 

Symptomatology. — The period of incubation lasts from seven 



WHOOPING-COUGH. 157 

to ten days. The disease proper begins with the catarrhal 
stage, which in no wise differs from any other catarrh involv- 
ing the respiratory mucous membrane. There is coryza; the 
discharge from the nose and eyes is watery, copious; there is 
shivering, some fever, with usually moderate elevation of tem- 
perature, rarely more than 101°, and dry, frequent, hacking, 
bronchial cough, which gradually increases in frequency and 
severity, and in some cases within a few days betrays the con- 
vulsive tendency. In from seven to ten, or more, days the con- 
vulsive or paroxysmal stage begins, with the first well-defined, 
clear-cut paroxysm of coughing. The onset of this stage may 
be abrupt; oftener it is the reverse. The paroxysm itself 
begins with a series of sharp, dry, very hard coughs, following 
each other quickly, with rapidly increasing difficulty of breath- 
ing and distress, which is plainly expressed in the anxious, 
frightened expression of the child's face and in its eagerness to 
find comfort in the arms of mother or nurse. The cough fre- 
quently is interrupted by loud, shrill inspirations, the result of 
spasmodic closure of the glottis, and the paroxysm finally 
ceases with an intense deep inspiration, causing the loud 
"whoop" which has given the disease its name. These par- 
oxysms occur both night and day; they are more frequent at 
night, and average from four or five to fifty, or more, seizures 
during the twenty-four hours. 

During the cough, there are present symptoms which denote 
insufficient aeration of the blood; the face becomes dusky, the 
eye-balls protrude and become congested; the forehead, hands 
and body are covered with a cold sweat; the sphincters may relax; 
in fact, danger of suffocation seems imminent, when relief is 
suddenly had by the entrance of air into the lungs. The fits of 
coughing thus continue until there is expectoration or until 
there is thrown off by what seems a combined cough and vom- 
iting a considerable amount of tenacious, glairy mucus, after 
which an interval of rest is had. 

The stasis which marks these paroxysms may give rise to 
haemorrhages, as into the conjunctiva, or to bleeding from the 
nose, ears, or into the brain; the violence of the concussion 
itself may cause rupture of the ear-drum or even hernia. The 
physical signs consist of a few moist rales and the signs which 
are peculiar to existing complications. The paroxysm over, 



158 SPECIFIC INFECTIOUS DISEASES. 

the little patient rests, then plays as usual until he is conscious 
of the approach of another fit, when the symptoms described 
again occur. The premonitory symptoms of an attack, from 
the statements of children old enough to express themselves in- 
telligently, are either a tickling in the throat or a sense of con- 
striction, of threatening suffocation. It is difficult to overlook 
the close resemblance of these seizures to affections of a purely 
neurotic origin. As Whittaker says: "It would appear as if the 
nerve centres suddenly discharged themselves of accumulated 
irritation, as in the case of epilepsy. Close observation of a 
case gives rise to the impression that the poison accumulates 
gradually up to a certain point, when it may be no longer 
stored and is discharged with the explosion that characterizes 
a paroxysm of the disease." If the premonitory symptoms de- 
scribed are looked upon in the light of an epileptic aura, the 
likeness is complete. 

The attacks may be excited by anything that irritates the 
throat, as the inhalation of dust, laughing, crj'ing, touching the 
throat, swallowing, etc. Moral causes may have the same ef- 
fect; thus, anger or other violent emotions, or hearing another 
child cough, will bring on a paroxysm. 

If the disease is violent, the general appearance of the child 
shows exhaustion; the eyelids are swollen; the skin is pale; 
the veins relaxed and blue; an ulcer is commonly seen under 
the tongue, which at one time was presumed to hold some 
aetiological relation to pertussis, but is probably the result of 
injury done the fraenum during the paroxysms of coughing. 
There is no fever during this stage, except as toward evening 
a slight elevation of temperature (100° to 101°) may occur or 
arise from some existing complication. 

A diminution in the number of paroxysms indicates ap- 
proaching recovery; the seizures become lighter as well as less 
frequent, and in the course of three or four weeks from the be- 
ginning of the convulsive stage, sometimes not for as many 
months, the stadium decrementi commences, and the patient 
gradually gets well. Exacerbations and relapses, however, are 
by no means uncommon. 

Complications and Sequelae. — Among the minor complica- 
tions the various hemorrhagic effusions incidentally mentioned 
occur with considerable frequenc\^; haemoptysis is not unusual; 



WHOOPING-COUGH. 159 

haemorrhage from the bowels is rare. Convulsions from blood- 
pressure upon the brain are occasionally noted during the par- 
oxysms, and permanent harm, such as monoplegia, hemiplegia 
and even death, may result in exceptional instances. Pleurisy, 
pneumonia, and insterstitial emphysema are among the pulmo- 
nary complications which arise. Lobular pneumonia follows 
in the wake of severe bronchitis when it involves the finer bron- 
chial ramifications; it is a very serious complication, runs a 
tedious course, and may terminate fatally, direct or from ex- 
haustion and inanition. Croupous and diphtheritic inflamma- 
tions of the pharynx and larynx, and not infrequently diar- 
rhoea, are also observed. 

Dilatation of the alveoli from the great pressure they are 
called upon to resist may produce acute or chronic emphysema. 
In children who are weakly, or badly nourished, or of tubercu- 
lar predisposition, whooping cough not infrequently acts as the 
exciting cause of pronounced tubercular disease, and thus pul- 
monary tuberculosis is added to the list of serious sequelae; this, 
in fact, so often occurs that great pains must be taken dur- 
ing the stage of convalescence with children whose history is 
in the slightest degree suspicious. Paralytic affections, from 
neuritis, are occasionally, but not often, noticed. 

Diagnosis. — A positive diagnosis is impossible during the ca- 
tarrhal stage. As the cough becomes more and more incessant, 
especially during epidemics of whooping cough, suspicion will 
be aroused; the convulsive stage having well developed, a mis- 
take can not readily be made. 

Prognosis. — The prognosis is good in uncomplicated cases; 
yet, complications are so frequent that pertussis is really a 
disease to be greatly dreaded in changeable, severe climates. 
The average rate of mortality is from 3 to 5 per cent.; it has 
reached 48 per cent, during the second year of life. It is safe to 
state that the younger the patient, the more serious the dis- 
ease. Secondary pneumonia must always be looked upon as 
a grave complication. 

The frequency of the paroxysms directly affects the progno- 
sis; if more than fifty paroxysms occur during the twenty -four 
hours, the case is serious; if the number of seizures is more than 
sixty in the same length of time, the prognosis must be ex- 
tremely guarded. Delicate, badly nourished children and the 



160 SPECIFIC INFECTIOUS DISEASES. 

very aged can offer comparatively slight resistance, and readily 
succumb where others recover. 

Treatment.— Prophylaxis here practically means isolation of 
the patient in order to protect other members of the family. In 
view of the now generally accepted belief that the sputum con- 
tains the medium of direct communication of the disease, the 
handkerchief as a receptacle of the expectoration is not allow- 
able, and a cuspidor or a basin containing water must be used 
for that purpose. Parents must be cautioned to keep from 
school or from association with other children those suspected 
of having the disease. If possible, in the case of city patients, 
the little one should be sent into the country; when that is im- 
practicable, it should at least be supplied with an abundance 
of fresh, pure air. During the catarrhal stage, especially if the 
symptoms are at all severe, the child should be kept in bed. 
The atmosphere of the sick room must be slightly humid; to 
this end a basin of water should be kept on the stove. A spray 
of carbolized water, or sheets wrung out of carbolized water, 
hung up in the room, answers the same purpose. Drink may 
be given freely and an abundance of easily digested food be al- 
lowed; it is wise to see that dry, "crumbling" articles of food 
are kept from the child, since they may excite the cough. 

Among the agencies used in severe cases for the relief of the 
irritation in the throat, a reasonably strong solution of 
Cocaine applied with a brush, or inhalations through the steam 
atomizer of vapor medicated with carbolic acid, deserve special 
mention. The latter particularly has proved of great service. 
If bronchitis develops, hot applications to the chest and hot 
baths are indicated. 

Particular pains must be taken to prevent imprudence and 
exposure during convalescence, so as to avoid the development 
of sequelae. If the attack has been long-continued and severe, 
the patient may for an indefinite length of time require con- 
stant and skilled medical care to insure perfect recovery; this 
applies most emphatically to children of tubercular predisposi- 
tion. 

Therapeutics. — Belladonna is especially useful in full- 
blooded, hearty children of nervous temperament. The cough 
is rough, barking, paroxysmal, excited by tickling in the 
larynx, and accompanied often by a sensation of "choking" 



WHOOPING-COUGH. 161 

tightness in the throat. It is aggravated by talking, swallow- 
ing, deep inspiration, touch. It covers the catarrhal stage of 
many cases, when the discharge from the eyes and nose is hot, 
with flushed face, roaring and beating in the ears, dryness of 
the nose, dull frontal headache. White coating of the tongue, 
which at times is red on the edges. Dryness of the mouth, with 
foul, slimy taste in the mouth. Dryness of the larynx. Asth- 
matic feeling in the throat and chest, with cough from dryness in 
the larynx, from tickling-itching in the back part of the larynx. 
Cough with expectoration of a considerable quantity of 
tough mucus. Its applicability to spasmodic states is marked 
and the tendency to congestion so pronounced as to render 
it strictly homoeopathic to many cases in the convulsive 
stage. — Antimonium tartaricum has proved of especial value 
when pulmonary complications existed. Given low, it favors 
free expectoration and is of great value when large mucus 
rales are present or when the involvement of the finer bronchi 
is extensive. In the early catarrhal stage it is of slight value. 
There is violent tickling in the windpipe, causing cough, worse 
after midnight; has to sit up on account of the oppression and 
dyspnoea; coughing-spell begins with suffocative feeling; crow- 
ing, gasping for air, finally relieved by copious mucous expec- 
toration; cough after getting angry and provoked; large ac- 
cumulation of mucus in the bronchial tubes, inhibiting the 
child from coughing; great prostration. — Cuprum promises 
most in cases where the convulsive element is prominent. 
The paroxysms of coughing seem interminable and exceedingly 
distressing, threatening the patient with suffocation. They 
occur frequently and are excited by talking, eating solid food, 
by mucus in the trachea, cold air, in fact by anything that ir- 
ritates the parts. The face is haggard and pale or cyanotic 
and sunken. There may be spasmodic rigidity of the entire 
body. Relief from drinking cold water is characteristic of 
Cuprum. The constriction of the chest is usually well pro- 
nounced; froth gathers about the lips during the fit; the rat- 
tling of mucus in the chest is audible; expectoration is pain- 
fully difficult and may be accompanied with vomiting of bile 
and blood. — Coralxium rubrum was one of Teste's favorite 
remedies in tussis. It is best suited to children of a nervous 
temperament. The attacks of coughing, while frequent and 
11 



162 SPECIFIC INFECTIOUS DISEASES. 

painful enough, are yet much less violent than under Cuprum, 
and the convulsive feature is more localized; the seat of the 
spasmodic action is in the la^nx and trachea; vomiting of 
mucus is not deferred as long' as under Cuprum.— Ipecacu- 
anha is most useful during the latter part of the catarrhal 
stage. There is gastric uneasiness, with disposition to retch 
and vomit; aversion to food, due to constant, slight nausea; 
cutting and pinching pain in the abdomen with, at times, diar- 
rhoeic movements; peevishness and irritability of the patient. 
Rattling of mucus in the chest and throat, with frequent hard 
coughing and gagging and vomiting during the spells of cough- 
ing; the expectoration consists of flat-tasting, sweetish mucus, 
occasionaly freely streaked with bright blood. There is much 
distress of breathing when coughing; the face becomes purple 
from the violent effort to cough and from the strangling; the 
patient is left greatly exhausted from the violence of the cough. 
Breathing sounds "asthmatic."— Naphthaline has been used 
rather empirically, and at times with very satisfactory results. — 
Hyoscyamus, Anacardium, Asafcetida, Cerium oxal., Mos- 
chus, and others, are suggested by nervous symptoms peculiar 
to them; Kali bichrom., Spongia, Bryonia, Drosera, Sam- 
bucus, Kali carbon., and others, are called to mind by well- 
known peculiarities of the "cough" itself rather than any spe- 
cial similarity to the totality of symptoms presented by the 
typical case of pertussis. 

Hale recommends, among others, Phenacetine, in doses of 
from 2 to 10 grs. of the first dec. trit., and of 3 to 5 grs. of the 
crude drug to adults, repeated every three to four hours. 

I firmly believe that success in the treatment of whooping 
cough depends upon the intelligent selection of the homoe- 
opathically indicated remedy and - pluck in continuing its exhi- 
bition so long as the symptoms of the case call for it. Lilien- 
thal (Homoeopathic Therapeutics) gives the indications of 
eighty-five remedies to which the reader is referred for further 
study. 



CEREBRO-SPINAL MENINGITIS. 163 



CEREBROSPINAL MENINGITIS. 

Synonyms: Epidemic Meningitis. — Meningeal Fever. — Pe- 
techial Fever. — Spotted Fever. — Malignant Fever. — Malig- 
nant Purpuric Fever. — Cerebral Typhus. 

An acute infectious disease which occurs epidemically and 
sporadically, and manifests itself chiefly by the virulent action 
of the specific poison upon the cerebro-spinal meninges. It is 
characterized by suddenness of invasion, intense pain in the 
back of the neck and spine, tetanic rigidity and contraction of 
the muscular fibre, especially of the posterior muscles of the 
neck, hyperesthesia, vomiting, lowered arterial tension, mod- 
erate elevation of temperature, great depression of the vital 
powers, the presence, usually, of herpetic or vesicular eruption, 
purpuric spots, or petechias, and the occurrence, nearly always, 
of coma before death. Convalescence is generally protracted 
and recovery incomplete. 

/Etiology. — Spotted fever was first recognized and studied 
clinically during an epidemic which occurred at Geneva in 1805; 
is was first observed in the United States in 1806. It is an epi- 
demic of rare frequency, but isolated sporadic cases are ob- 
served constantly in different localities. It is undoubtedly in- 
fectious, but as yet nothing positive is known concerning the 
specific virus which is its direct cause. Various micro-organ- 
isms have been found and described; of these, the pneumococ- 
cus, or a microbe closely resembling it, discovered in the men- 
ingeal exudation of persons dead from the disease, has at- 
tracted most attention. It is not known how the infectious 
principle gains entrance into the system. Neither has it been 
determined whether, or not, the disease is contagious. The 
fact that those who are in daily attendance upon persons ill 
with the fever do often wholly escape, and that frequently only 
isolated cases occur in large families, argues against its con- 
tagiousness or transmission by clothing or excreta. Yet, 
well authenticated cases have been placed on record where by 
contact with infected garments the fever was communicated 
to a number of persons living at a considerable distance from 



164 SPECIFIC INFECTIOUS DISEASES. 

the person originally infected and from each other, and in some 
cases brought in contact with the contaminated garments 
weeks and months after the first case had occurred. It seems 
also as though certain houses and localities may be infected, 
for in several instances the disease has appeared among the 
successive occupants of certain buildings (as barracks), the 
same parties, upon change of residence, remaining free from 
the infection. 

The disease does not follow lines of travel, but appears unex- 
pectedly in localities widely separated. Thus, the epidemic at 
Geneva in 1805 was followed in 1806 by outbreaks simultane- 
ously in Germany and in the United States. 

The disease has shown a decided preference for the northern 
portions of the temperate zone and for the cold seasons of the 
year, cases being most frequent and especially severe during the 
winter months. It appears from statistics that its victims 
usually are the young. With the exception of soldiers, who 
among adults are particularly liable to the disease, cerebro- 
spinal meningitis most readily attacks children and young peo- 
ple from the fifth to the sixteenth year; it has proved especially 
fatal in infants less than one year old (Report of the N. Y. 
Board of Health). 

Wolff, from an analysis of 132 cases, concludes that moisture 
of air and soil constitutes a predisposing cause. Insanitary 
surroundings, filth, and overcrowding of population have no 
influence, for localities free from these objections have furnished 
many marked cases, while filthy and overcrowded districts of 
large cities, like London and New York, have remained free. 
Fatigue, exposure, low state of vitality from previous illness, 
etc., can be considered only in the broadest sense and, like race, 
sex or age, have no direct bearing upon the question. 

Morbid Anatomy. — Rigor mortis is marked and decomposi- 
tion sets in early. The principal changes are in the brain and 
spinal cord and their coverings, consisting of great hyperemia, 
inflammation, inflammatory products, and structural changes. 
The hyperemia is general, involving the vessels, sinuses and 
covering membranes of the brain and cord. The dura mater ad- 
heres to the arachnoid, and effusion of serum, sometimes of 
pus, is found between the two. The pia mater in severe cases 
shows exudation and infiltration into and within its meshes. 



CEREBROSPINAL MENINGITIS. 165 

Pus is found in the fissures; the entire surface of the brain may 
be bathed in pus. The pia mater often firmly adheres, in spots, 
to the brain, which shows hemorrhagic spots and more or less 
extensive areas of softening. Corresponding changes are noted 
in the spine. Both cranial and spinal nerves, especially the 
auditory and the optic, are deeply involved, with exudation 
along their lymphatic sheaths and pus bathing their roots. 
Neuritis and perineuritis are common. 

The muscles are dry, pale; sometimes granular degeneration 
is present. The heart is flabby, and the blood, in malignant 
cases, fluid. There is hypostatic congestion of the lungs and 
pneumonia. Congestion of liver and kidneys, at times neph- 
ritis. Enlargement of the spleen, in proportion to the intensity 
and duration of the fever. Extensive ecchymoses; dusky, mot- 
tled appearance of the internal organs. 

Symptomatology. — In the average case the onset of the dis- 
ease is sudden. If there is a prodromal stage, it lasts from 
several hours to several days, and presents no characteristics, 
being simply a state of general depression and malaise. Usually, 
a hard chill appears between noon and midnight, with severe 
headache, dizziness, vomiting, pale face, expressive of much suf- 
fering, slight fever and full, rather heavy, pulse. In children 
convulsions often are present from the beginning. The head- 
ache commonly is frontal, sometimes occipital, very severe, lan- 
cinating, constant or intermitting. There is sensitiveness to 
light and noise, with irritability and restlessness. In children, 
delirium, often wild, is a common and early symptom. On the 
second or third day symptoms of spinal irritation show them- 
selves, with stiffness and pain of the muscles of the neck and 
back, retraction of the head, and opisthotonos. Severe sharp 
pain in the muscles of the spine and extremities follows, with 
tonic spasms giving rise to intense suffering. The convulsive 
tendency becomes more and more pronounced, even involving 
the muscles of the face, not infrequently, especially in children, 
assuming an epileptiform type, with unconsciousness, and giv- 
ing rise to local paralysis, as of the muscles of the face and 
eyes. Strabismus, inequality, dilatation or contraction of the 
pupils, with insensibility to light, are present. With these, 
there is vertigo, ringing in the ears, hypersensitiveness of spe- 
cial senses, general and remarkable hyperesthesia all over the 



166 SPECIFIC INFECTIOUS DISEASES. 

body, delirium, which at times alternates with stupor, and 
temporary, sometimes permanent, loss of hearing and vision. 
Vomiting may prove persistent and distressing. There is no 
taste or appetite and usually no thirst. Constipation, rarely 
diarrhoea. Slightly increased flow of (albuminous) urine. En- 
largement of the spleen. 

The fever is variable, sometimes quite high, but generally mod- 
erate if the intensity of the general symptoms is considered; 
it presents no characteristic temperature curve. The pulse rate 
also is less affected than would be expected from the violence of 
the constitutional symptoms. Breathing often is "sighing," 
a slow, labored inspiration, followed by quick expiration and a 
long pause. An eruption commonly appears, varying from fever 
blisters about the mouth and lips to a general rash which may 
resemble that of measles, scarlet fever, or typhus, or appear 
blotch-like, petechial or ecchymotic. 

In five to eight days from the declaration of the attack, a 
gradual and increasing amelioration of the symptoms shows 
itself, and the patient drifts into a state of convalescence which 
is modified by the severity of the attack and the appearance or 
non-appearance of complications and sequelae. 

If, on the other hand, the tendency is toward a fatal issue, 
a state of exhaustion follows the continuous excitement which 
has so far existed. The patient drops into a typhoid condition; 
the tongue becomes dry, red, brown and sooty; thirst is con- 
stant, though not often intense; the bowels are stubbornly 
constipated or diarrhoea supervenes; then follow tremulous 
restlessness, extreme exhaustion, rapid and light pulse, contin- 
uously sustained high temperature, coma, paralysis of the 
sphincters, and finally, sometimes after weeks and even months, 
death from asphyxia or exhaustion. 

Cases occur in which the symptoms are limited to moderate 
headache, with vertigo, nausea, slight, if any, fever, and little, 
if any, pain and stiffness in the neck and back. Although cases 
of this type may suddenly assume a serious aspect, they^ 
usually recover within a few days. This is the mild form of the 
disease. 

In others the onset may be typically sudden and violent, but 
in a few days a change for the better takes place and a quick 
recovery results. In these cases, as Pepper remarks, the initial 



CEREBROSPINAL MENINGITIS. 167 

constitutional infection is pronounced, but the other essential 
constituent of the disease, the meningeal inflammation, is 
present in a very light measure. This is the abortive form. 

Again, marked intermissions may be observed, daily or every 
other day, exacerbation of all the symptoms being followed 
by a temporary and pronounced subsidence; these intermis- 
sions are somewhat irregular, unlike those of malarial origin; 
they may occur at the beginning or toward the close of the 
disease, and are oftenest seen in moderately severe but tedious 
cases. This is called the intermittent form. 

Or the onset of the disease may be exceedingly sudden and 
the symptoms of very great violence from the start, the patient 
passing rapidly into a state of collapse. Here the action of the 
specific poison upon the nerve centres is shown by even more 
than usual intensity of the headache, excessive prostration, 
feeble and thread-like pulse, subnormal temperature, coldness 
and clamminess of the skin, cyanosis, slow and labored respira- 
tion, delirium rapidly tending to coma, scanty, albuminous 
urine, and purpuric, ecchymotic eruption. Violent convulsions 
are rarely present. Such cases tend toward a fatal issue in five 
to twenty-four hours; if reaction takes place, recovery is sure 
to be very tedious and rarely complete. This is the fulminant 
form. 

Special Symptoms.— The cephalalgia is always present, save 
when the intensity of the specific poison has overcome all sensi- 
bility; it is expressed by corrugation of the eyebrows and fre- 
quent raising of the hand to the head. It probably arises from 
mechanical pressure upon the cranial and upper spinal ganglia. 
The spinal pains also are intense; they may extend throughout 
the cord, but oftener are limited to the cervical portion; they 
are neuralgic, darting, pricking, lightning-like, and may be ac- 
companied by a sensation of numbness. The pain in the back 
is of a "dragging" character; involuntary effort to gain relief 
is undoubtedly in part responsible for the characteristic bend- 
ing backward of the head. Cutaneous hyperesthesia is pro- 
nounced; it may eventually give way to numbness and anaes- 
thesia. Convulsions are more frequent and earlier in children 
than in adults, and may affect any or all the muscles. Exhaus- 
tion of energy and paralysis eventually result from their 
violence. General paralysis indicates a fatal termination. 



168 SPECIFIC INFECTIOUS DISEASES. 

Eye. The symptoms here are mainly due to cerebral involve- 
ment, in part directry to the disturbance of the muscular appara- 
tus. In protracted and severe cases permanent harm ma}' result 
from inflammation of the cornea and iris, the former ending in 
opacity or ulceration, the latter in effusion of lymph or pus. 
Hearing- is often permanently injured or lost as the result of 
purulent inflammation of the labyrinth, suppurative inflamma- 
tion of the middle ear, or of auditory nerve-atrophy. Vertigo is 
of cerebral origin; it is aggravated from attempts to arise from 
a recumbent posture; it is accompanied with nausea, faintness, 
quickened pulse, staggering gait, and tendenc}- to fall to the 
ground when attempting to stand or walk. Children especially 
suffer from it, even after convalescence has been well estab- 
lished. Organs of digestion. Vomiting is chiefly of cerebral 
origin; thirst is rarely marked; in the fulminant form coffee- 
colored masses ma}' be vomited in large quantities; constipa- 
tion usually exists, but diarrhcea may prevail, especially in 
grave cases; the tongue at first is clean and moist; later it 
has a thick, whitish coating, especially in the centre and at 
the tip and edges; in the typhoid form it is dry, red, rough, 
parched, cracked. The urine generally is normal, slightly in- 
creased in amount; retention may occur during coma; albu- 
min, casts and blood corpuscles are seen in serious cases. The 
pulse at the beginning of an attack may drop as low as forty 
beats per minute, and even lower, later rising considerably 
above normal, as 120 to 130. It is a soft, rather unsettled 
pulse, increased, even doubled, from slight exertion, as raising 
from a recumbent posture. The temperature has no character- 
istic curve; it is somewhat higher than normal in the axilla, 
varying from 100° to 103°. It often fluctuates without appre- 
ciable cause; sudden rise or fall indicates danger. The eruption 
is exceedingly variable; not infrequently it is wholly wanting; 
in others it is an exanthem indicating a depraved state of the 
blood rather than a characteristic lesion. The name "spotted 
fever" is derived from the dark, purplish, mottled appearance 
of the skin and internal organs which pertains to the grave 
type of the disease; these spots are oval in shape, and from one- 
third to one-half of an inch in their longest diameter. Herpes 
labialis, simple erythema, dermatitis, miliary, herpetic, vesic- 
ular eruptions, petechias and ecchymoses are seen in different 
cases, types, and epidemics. 



CEREBROSPINAL MENINGITIS. 169 

The duration of the disease varies from a few hours to a few 
days in the fulminant form, and from days to months in com- 
plicated cases. The average duration is from twenty-four to 
thirty days. 

Complications and Sequelae. — The complications most likely 
to arise are those of the respiratory organs, chiefly pneumonia; 
also pleurisy, bronchitis, atelectasis, endocarditis, pericarditis. 
Intestinal catarrh and (parenchymatous) changes in the liver 
and kidneys, measles, scarlet fever, typhoid fever, cholera and 
malarial fever must also be mentioned. Among the sequelee, 
deafness and blindness are common, especially the former, as 
proved by the reports of asylums. Paralytic affections, result- 
ing from neuritis and perineuritis, are frequent; they usually 
recover in the course of several months. Speech may become 
permanently injured; severe headaches may persist for an in- 
definite length of time; mental feebleness may result, and an 
unmanageable form of hydrocephalus may develop in children. 
Relapses occur so often that a "chronic form" of the disease 
has been described. 

Termination. — The termination of the disease is toward per- 
fect recovery, imperfect recovery, or death. Imperfect recovery 
is frequent on account of the complex nature of the cases and 
the tendency to serious sequels which depends upon the pro- 
found exhaustion of the vital forces and the structural changes 
which are incidental to the affection. These factors also affect 
the death rate. In children the prognosis is always grave. 

Ureemia, persistent low typhoid state, prolonged high fever, 
great blood dyscrasia, sudden and great rise or sudden fall of 
the temperature point toward an unfavorable prognosis. 

In epidemics the rate of mortality is from 20 to 80 per cent. 
The highest rate of mortality usually occurs in the early part 
of an epidemic. 

Diagnosis. — In the absence of an epidemic and of pathogno- 
monic symptoms (eruption, characteristic pain and stiffness in 
back and neck, headache, hyperesthesia, etc.) it may be difficult 
to recognize a mild, sporadic case. During an epidemic, and 
when the disease is well pronounced, there should be no diffi- 
culty. Tubercular meningitis is not influenced by the season of 
the year; there is usually evidence of an inherited tubercular ten- 
dency. The onset is gradual and the prodromal stage prolonged; 



170 SPECIFIC INFECTIOUS DISEASES. 

the course of the disease is more tedious, and the termination 
always fatal; the pulse is much more irregular; there is less spinal 
irritation, less retraction of the head, less pain in the extremities, 
and much less hyperesthesia. The "sighing respiration" ismore 
marked. The ophthalmoscope proves the presence of tubercle 
in the choroid. — Typhoid fever with cerebral involvement may 
closely resemble cerebro-spinal meningitis; but it lacks the de- 
cided preference for early youth, is slower in onset, presents 
no spasms, has a characteristic temperature curve, character- 
istic eruption, abdominal tenderness, diarrhoea, and much 
greater enlargement of the spleen.— Typhus fever is contagious 
and is limited to certain exposed localities, as seaports. It has 
a preference for adults; a high initial fever with characteristic 
temperature curve and distinct eruption, first roseolous, then 
petechial; its headache, usually, is dull; delirium occurs late, 
and is "muttering;" vomiting and convulsions are not so fre- 
quent as in spotted fever; there is much less pain and muscular 
rigidity. Distinct "mousy" odor of the body.— Pernicious ma- 
larial fever occurs in favored regions and seasons of the year; 
it has a well-defined aetiology. Although it rapidly develops 
collapse and coma, the first paroxysm is rarely fatal. There 
is greater splenic enlargement; presence of malarial organisms 
in the blood; prompt and specific action of quinine. — Influenza 
with meningeal involvement may so closely resemble cerebro- 
spinal fever, even to the sequelae, that a positive differentiation 
is not always possible. — Malignant scarlet fever is determined 
by the presence of characteristic throat symptoms, b}' the early 
appearance of the specific rash, with desquamation and itch- 
ing. In case of death before the appearance of the eruption a 
positive diagnosis may be out of the question.— Rheumatic 
fever without articular involvement and with trismus, great 
muscular soreness and rigidity, and with meningeal irritation, 
and smallpox of the malign ant form, terminating fatally before 
the occurrence of the eruption, may present symptoms which 
make a clear diagnosis impossible. — Secondary meningitis also 
presents difficulties; the history of the case, the comparative 
lightness of the hyperesthesia and of the stiffness of the muscles 
of the neck and back must be taken into consideration. 

Treatment.— Prophylaxis is almost out of question; yet, in 
view of the bad effect which insanitary surroundings exert under 



CEREBROSPINAL MENINGITIS. 171 

all circumstances upon the well no less than upon the sick, it is 
wise to take especial pains in the presence of a threatened epi- 
demic of this, or any other, disease, and to strictly enforce san- 
itary regulations, as applied to public and private property and 
to persons. Fatigue and exposure should be avoided. A case 
having appeared in a house, the building should, if possible, be 
vacated at once by the inmates not yet affected; linen, cloth- 
ing, and everything at all likely to transmit the disease, should 
be thoroughly disinfected or destroyed. 

The patient should be placed into a large room, as far re- 
moved from noise as possible; the room must be well ventilated 
and kept at a temperature of about 65°; curtains should be in 
place, so as to exclude light when desirable. Particular pains 
are to be taken to insure quiet and to so arrange the work 
about the sick-room that there is about it no "fussing"; no su- 
perfluous attendant is to be allowed about the sick. From 
first to last every care must be exercised to avoid the slightest 
unnecessary exertion on part of the patient; so pernicious in its 
effects is moving about, that the linen should not be changed 
oftener than absolutely necessary, and an uncomfortable posi- 
tion of the patient is to be considered preferable, for a short 
time, to a change which involves exertion, waste of energy, and 
often considerable pain. If the patient is delirious or hypersen- 
sitive to external impressions, the room must be kept moder- 
ately dark. 

For the relief of the headache, hot mustard foot-baths are 
recommended; they afford relief by drawing the blood from 
the head. General bleeding is now rarely practiced, but local 
bleeding, by leeches behind the ear, or by wet cupping, is still 
advocated; dry cupping has the same effects, and saves the 
loss of blood. The practice of placing ice-caps to the head, or 
ice-bags or ice in rubber tubes to the spine, has earnest advo- 
cates. Blistering, once very popular, is now rarely employed; 
the Paquelin thermo-cautery is recommended -when counter-ir- 
ritation along the spine and back seems necessary. Hot water 
baths are useful when the temperature ranges above 102.5°. 
Sponging in hot water is almost invariably grateful to the pa- 
tient; it relieves the restlessness and the pain. 

Phenacetine, in small and frequent doses, has been given to 
relieve the pain; its depressing effect renders caution in its use 



172 SPECIFIC INFECTIOUS DISEASES. 

necessary. Mercury and Quinine have proved useless. Opium 
in large doses, one grain every hour in severe, and every two 
hours in lighter, cases constitutes the sheet anchor of the domi- 
nant school; it must be prescribed cautiously in children. 

The diet should be nutritious throughout, first liquid, later 
solid. Milk, broths, scraped raw beef, eggs, sweet-breads, 
fowl, etc., constitute the* staples of an appropriate dietary. 
Overfeeding must, for obvious reasons, be avoided. If at any 
time feeding by the mouth becomes difficult, rectal alimentation 
or feeding by the stomach-pump is indicated. Water may be 
drunk as the patient desires. 

Stimulants are borne kindly and in large amounts. When- 
ever exhaustion becomes apparent, they may be prescribed. 
Brand3^ and whiskey are to be used when the heart flags. 

Constipation rarely becomes troublesome; if it does, castor- 
oil in proper doses is preferable to enemata, for the latter ex- 
haust the patient. Retention of urine calls for the use of the 
soft catheter. If vomiting is persistent, small bits of ice, 
cooled champagne, milk and lime-water, or sips of very hot 
water, may give relief. Persistent hiccough, if it fails to yield 
to the indicated remed\ r , may demand the subcutaneous use of 
Morphine. 

During convalescence extreme care must be exercised to pre- 
vent relapse. Judicious feeding and well regulated exercise are 
important. The electric current, effusions of cold and hot 
water to the spine, or alternating streams of cold and hot 
water, as well as massage, will prove efficient in overcoming 
the weakness and paralysis of affected nerve trunks. 

Therapeutics.— Gelsemium: In the light, mild form it acts 
especially well on children and sensitive, nervous persons. 
There is chilliness, moderate fever, great general lassitude and 
weakness in the legs, dull heavy headache, dizziness, stupid ex- 
pression of the face; "wants to be let alone;" rheumatic and 
myalgic pains in different parts of the body; symptoms of a 
malarial character.— Agaricus: Stupefaction and vertigo, as 
if the brain were in a whirl. Stitches through the brain as if 
he were to lose his senses. Burning at the vertex, with stupe- 
faction and vertigo. Painful pressure in the head and eyes. 
Tearing pain in various parts of the body; in the sacrum, as if 
it would fly to pieces. Digging aching in the posterior cervical 



CEREBRO-S PINAL MENINGITIS. 173 

region. Muscular twitchings at the left knee, arm, back, etc. 
Twitching of the eyelids, eyeballs, and facial muscles. Shock 
of the entire body, the arm being jerked downward. Fainting- 
turns, with inclination to vomit. Stinging burning pains deep 
in the vertical column. Pain in the eyeball; weakness of sight. 
Buzzing and purring sensation in the ears. Paralysis of arms 
and legs. Vesicular eruption of the size of millet seeds. — 
Cicuta: Countenance ashy, bluish-pale, cold; pupils dilated, 
insensible; jerking of the eyeballs and spasmodic contortions of 
the facial muscles; teeth are set, and there is inability to swal- 
low. Violent occipital headache, severe vertigo, reeling on 
stooping. Violent hiccough. Tetanic rigidity of the muscles of 
the neck, -with retraction of the head. Dumbness and deafness. 
Excessive dyspnoea from tonic spasm of the muscles of the 
chest. Trembling of the limbs; startings and convulsive move- 
ments of the limbs; convulsions with violent outcries, suspen- 
sion of breathing and foaming at the mouth. Violent jerks 
through the head, arms, and legs. Tonic spasms, renewed 
from the slightest touch. Opisthotonos.— Nux: Terrible ache 
in the occiput, which feels sore and bruised from stitching, lan- 
cinating pains which fly through the body with the swiftness 
and fierceness of chain-lightning, and from violent convulsions, 
without loss of consciousness, excited by the least touch. 
Tearing pain in the nape of the neck and in the back; draw- 
ing, jerking pains from the orbit to the occiput. Great hyper- 
esthesia.— Cimicifuga: Intense pain in the head, particularly 
at its base and along the spine; great sensitiveness of the spine; 
rigidity of the muscles of the neck and back, with retention. 
The brain feels too large. Marked sensitiveness of the skin, 
with circumscribed or diffused muscular soreness. Sleepless- 
ness. Alternate tonic and clonic spasms, night and day. Pain 
in the back, of a drawing, tensive character, or dull and heavy, 
with tenderness on pressure. Nausea and vomiting, especially 
with the headache. Spasmodic jerkings, like chorea. Erup- 
tion of white pustules on the face and neck, sometimes large, 
red, papular.— Ignatia: General resemblance to Nux. Difficulty 
of breathing from oppression of the chest; unconscious, sigh- 
ing respiration; great nervousness and irritability; erratic 
character of the pains; changeable, sad, moody disposition of 
the patient; convulsive movements slight, but- darting pains 



174 SPECIFIC INFECTIOUS DISEASES. 

severe. Physostigma: Contraction of the pupils; obstinate con- 
stipation, with flatulent distension of the abdomen; pain in the 
stomach immediately after eating. Tetanic spasms with irreg- 
ular, tumultous action of the heart. Epileptiform convul- 
sions. — Cannabis: Great pallor of the face; fixed gaze, dilated 
pupils; irregular, feeble pulse; cold face, with drowsy, stupid 
expression, sensitiveness to light and sound. Vertigo on rising, 
with stunning pain in the occiput; pain across shoulders and 
spine; paralysis of lower extremities and of right arm; convul- 
sions; emprosthotonos, with loss of consciousness; collapse; 
stupor; pale, clammy and insensible skin; feeble, irregular 
pulse; hysteria and hysterical hallucinations. 

Brain-symptoms predominating, Belladonna, Hyoscyamus, 
Bryonia, Opium, Cocculus, and especially Cuprum and 
Zincum, promise to be of service. — Belladonna is indicated in 
the early stage by the presence of S3^mptoms denoting violent 
arterial congestion; later, by deathly pallor, stupor, dull and 
heavy expression of the face, coldness of the extremities, with 
heat of the head; fixed and lifeless appearance of the eye; dry, 
dirty -brown tongue; retention of urine or involuntary mic- 
turition.— Hyoscyamus: Profound apathy; face pale, bloated, 
cold; small, quick, intermittent pulse; stupor; picking at bed- 
clothes; deafness; lock-jaw; eyes red, sparkling, protruding; 
pressive, stupefying headache; sensation as though the brain 
were loose in the skull; paralysis of the tongue; tongue red, 
dry, brown, fissured; cadaverous smell from the mouth. In- 
ability to swallow liquids, with spasms following the attempt. 
Convulsions of single muscles or of sets of muscles, followed by 
paralysis. Grinding of teeth; starts as if frightened. Shrill 
screams during sleep. Paralysis of rectum; cutaneous hyper- 
esthesia. — Bryonia: Vertigo, worse when raising the head; 
patient is irritable, with sense of confusion in the head. Stitch- 
ing, throbbing headache, from before backward, into the occi- 
put and neck; sharp, splitting frontal headache. Tenderness and 
soreness all over, as though bruised, with excessive tenderness 
over the scalp. Tongue thickly coated white; constant chew- 
ing motion of the mouth. Great thirst; vomiting of food, but 
not of drink; constipation; eruption all over the body, red, like 
measles. — Opium: Expression of face stupid; patient lies in bed 
motionless; face dark red and bloated, head thrown backward, 



CEREBROSPINAL MENINGITIS. 175 

eyes half closed, dilated or contracted, insensible to light, jaw 
dropping; respiration deep, slew, snoring. Tongue dry, 
brown; pulse usually light and quick, sometimes very slow. 
Flesh feels hot; copious perspiration. If raised from the pil- 
low, the head drops back as though too heavy for the neck 
and shoulders. Jerking and twitching of the limbs; sometimes 
convulsions and opisthotonos. Sweats during sleep; sensi- 
tiveness to sounds. Symptoms worse from sweating.— Coccu- 
eus: Pale, sallow, bloated face, covered with cold sweat. Hard- 
ness of hearing, with noise in the ears like rushing water. Vio- 
lent occipital headache, extending into the neck, with trem- 
bling of the head; headache with a sensation as if the eyes 
were being pulled out of the sockets. Dizziness, with inclina- 
tion to vomit when rising. Painful stiffness of the neck, with 
feeling of weakness as though unable to support the head. 
Weakness and paralytic trembling of the extremities. Spas- 
modic oppression of the chest, with heavy, labored breathing; 
sense of spasmodic constriction along the spine, worse from 
motion. Paralysis of face, tongue, pharynx. Hysterical and 
epileptiform convulsions; miliary eruptions.— -Cuprum: Of 
particular value in case of children. Stupor. Eyes sunken, sur- 
rounded with dark rings. Coldness of the hands; twitching 
and jerking of the limbs; spasmodic twitching and contortions 
of the muscles of the face. Child lies on the belly, spasmod- 
ically thrusting the breech upward. Violent fits of dyspnoea 
come on suddenly, continue for a few hours, then disappear as 
suddenly; threatening paralysis of the lungs. Gurgling noise 
when swallowing liquids. Clonic spasms beginning in the 
fingers and toes. Delirium, with great fear of everybody, ob- 
scuration of sight and difficulty of hearing. Bruised soreness 
and pressive pain in the head, made worse from turning the eyes. 
Paralysis of the muscles of the back and neck. — Zincum: Case 
severe, tedious, with great prostration. Frequent attacks of 
vertigo; impairment of memory; severe pressure on the vertex 
and forehead, with tearing pain as though the head would 
burst. Dizzy, stupefying headache, always with vertigo. In- 
tense pain in the head, with dizziness, shivering, followed by 
excessive vomiting of bile and trembling, relieved from perfect 
quiet. Anxiety, restlessness. Constant motion of hands and 
feet; rolling and tumbling of the head from side to side. 



176 SPECIFIC INFECTIOUS DISEASES. 

Starting from sleep, uttering piercing cries. Spasmodic twitch- 
ing of hands and feet. Weakness of sight; ravenous hunger; 
flatulent colic. Scant}', turbid urine, as if mixed with clay. 
Flashes of heat, alternating with spells of chilliness. 

Typhoid symptoms call for Arsenic, Bryonia, Rhus, Arnica, 
Baptisia, and other remedies of the same class; indications for 
their use may be found under "typhoid fever." 

If hlood-dyscrasia is pronounced, Crotalus and Phosphorus 
are also to be considered.— Crotalus covers the extreme ex- 
haustion, with great pallor, intense restlessness, severe head- 
ache, as from a blow on the occiput, intense thirst, vomiting, 
faintness, ecclrymoses, and other characteristic symptoms of 
a depraved state of the blood. — Phosphorus: Pulmonary com- 
plications. Countenance appears cadaverous, bloated; there is 
marked dyspnoea, worse from the slightest exertion; sensitive- 
ness of the spine. In case of collapse, energetic measures, as 
hot stimulating drinks, alcoholic stimulants and friction must 
be promptly used. Of internal remedies Camphora, Vera- 
trum album, Veratrum viride and Carbo yeget. are most 
likely to prove useful. 



ERYSIPELAS. 

Synonyms: St. Anthony's Fire. — The Rose. 

An acute infectious disease, of local origin, characterized by 
circumscribed or diffuse inflammation of the skin and subcuta- 
neous tissue, chill, fever, and malaise. 

Etiology. — The disease occurs independent of sex, age, occu- 
pation, atmospheric or tdluric conditions. It is endemic, at 
times, epidemic. It is contagious, and may be conveyed from 
person to person or transmitted through the agency of cloth- 
ing, furniture, bedding, etc. It occurs frequently in badly ven- 
tilated and insanitary institutions, such as poor-houses, hos- 
pitals, etc., but may prevail in model institutions in excellent 
sanitary^ condition. Local causes, as defective pipes, soiled 
bedding, etc., are intimately connected with erysipelas. It is 
generally believed that a wound (surgical operation, parturi- 



ERYSIPELAS. 177 

tion) or abrasion of the skin, possibly so slight as to escape de- 
tection, or the delicate structure of a new cicatrix, affords ac- 
cess to the specific streptococcus of erysipelas, and that the dis- 
ease does not arise save in this manner. The remarkable pref- 
erence shown by erysipelas for the face— the most exposed 
part of the body — is considered a strong argument in favor of 
this position. A low state of vitality (general debility, chronic 
alcoholism or exhausting disease, as albuminuria) and special 
liability to erysipelatous infection on part of individuals or 
families are important predisposing causes. It is admitted 
that one attack creates a predisposition to others. 

The streptococcus of erysipelas has not yet been dis- 
tinguished from the streptococcus pyogenes. Its presence gives 
rise to the local inflammation of the invaded tissues, and its 
toxine, absorbed into the system, is largely responsible for the 
constitutional symptoms which soon follow the invasion. 
The micro-organism is found in the largest numbers, not at the 
seat of active inflammation, but in the zone lying immediately 
beyond. 

Morbid Anatomy.— In addition to such changes, postmortem, 
as are peculiar to the visceral complications which may occur, 
there is evidence only of simple inflammation, with inflamma- 
tory oedema and, often, more or less extensive suppuration. 

Symptomatology.— The stage of incubation varies from three 
to seven days. It is followed by that of invasion, characterized 
by a severe chill, or several light chills, a feeling of general in- 
disposition, anorexia, gastric discomfort, nausea, sometimes 
vomiting, headache and fever, with a rapidly rising tempera- 
ture and, usually, scanty urination. In light cases the consti- 
tutional symptoms may be inconsiderable. Violent attacks 
frequently are ushered in by well-pronounced general symp- 
toms, occasionally delirium from the beginning. If, as is com- 
monly the case, the disease affects the face — and it runs the 
same course in any other part of the body, — slight redness will 
show itself over the bridge of the nose and upper cheek, or at 
the point of abrasion if located elsewhere. Heat, swelling, and 
redness rapidly increase, the inflammation extending in every 
direction, the parts presenting a tensely drawn, glazed, 
swollen, cedematous surface. It rarely involves or passes the 
chin. Slight vesiculations and bleb-like formations stud the 
12 



178 SPECIFIC INFECTIOUS DISEASES. 

skin, which is hot to the touch and itches intensely or burns 
like fire. The affected parts, especially on the forehead, are 
bordered by a raised, firm, well-defined line, distinctly felt. 

General oedematous swelling now becomes a conspicuous 
feature of the case, affecting both face and scalp, and greatly 
disfiguring the patient. The lids are swollen so as to close the 
eyes; the ears are much enlarged; the neck becomes involved, 
with much swelling of the cervical glands, though the enlarge- 
ment of the latter is not easily recognized, owing to the exten- 
sive oedema of the neck. After five or six days, during which 
time the temperature may remain continuously high, but 
rarely rising above 104°, defervescence b}' crisis will probably 
take place, recovery being characterized by perfect restitution 
of the parts involved. 

The constitutional symptoms differ according to the severity 
of the local inflammation and the age and vigor of the patient. 
Frequently, and even in cases where the local symptoms are 
violent, the sustained elevation of temperature is the most mark- 
ed general effect. In persons whose powers of resistance are 
low from advanced age, ill health, or evil habits, especially hard 
drinking, there maj^ be great depression from the beginning. 
The tongue then is heavily coated, the bowels stubbornly con- 
stipated, and the urine scanty and rich in albumin; soon the 
tongue becomes dry, glazed, brown; delirium, commonly of a 
muttering character, declares itself; the pulse becomes feeble and 
rapid, and death from toxaemia supervenes. 

Extension of the erysipelatous inflammation may occur, and 
thus the oral and pharjmgeal mucous membrane become in- 
volved; more rarely the larjmx is affected, and then extensive 
oedema, intensified by extension from without inward, consti- 
tutes a very distressing sjmiptom of the case; or the morbid 
process may from the face extend to the neck, chest, or other 
parts; or an actual reinfection may take place, as from a 
scratch with the finger-nail. In any of these contingencies the 
temperature at once assumes an upward direction as soon as 
extension to, or reinfection of, healthy tissue takes place. 

The formation of small cutaneous abscesses on the face and 
neck is not uncommon, and large amounts of pus frequently 
collect beneath the scalp. When restitution has taken place, no 
trace of the cutaneous inflammation is left. 



ERYSIPELAS. 179 

Complications. — Among the complications of erysipelas, sep- 
ticaemia, ulcerative endocarditis and albuminuria are the more 
frequent, the latter especially in persons of advanced years. A 
true nephritis is found occasionally, as is pneumonia. Brain- 
symptoms are often pronounced and of a character which sug- 
gests the existence of meningitis; yet, examination after death 
has failed to prove the existence of "meningeal disease, and the 
conclusion is drawn that the cerebral disturbances are due to 
toxaemia. A tendency to gangrenous complications is also ob- 
served, and is to be dreaded on account of the danger of col- 
lapse. 

The prognosis is good, except in persons previously debili- 
tated by old age, ill health, or evil habits. It is less favorable 
in traumatic cases and when erysipelas occurs as a complica- 
tion of Blight's disease. In the ambulatory form death from 
exhaustion may result. In the new-born, especially when the 
navel is attacked, the issue is usually fatal. Gangrenous com- 
plications are necessarily serious. 

Diagnosis. — The diagnosis rests 'upon the character of the 
eruption, the bright redness of the circumscribed area of inflam- 
mation, its mode of extension, the formation of blebs and 
bullae, the well-defined, hard and elevated margins which sur- 
round the area of inflammation, and the rise and decline of the 
fever in direct proportion to the intensity of the local symp- 
toms. 

Treatment. — To prevent the spread of the disease, the 
patient must be isolated, and neither physician nor nurse be 
allowed to approach persons specially predisposed to erysipelas 
by virtue of having open wounds or abrasions, such as lying-in 
women or surgical cases. Nurses and other attendants must 
also guard against abrasions and wounds on their own per- 
sons. Antiseptic measures, including the .proper care of the 
person of the sick, his clothing, bedding, the various utensils 
and instruments used, and of the room, are indispensable. All 
dressings must be destroyed by fire. After recovery or death 
of the patient the sick room and its contents must be thor- 
oughly fumigated and disinfected by corrosive sublimate wash. 
These precautions are doubly important in the wards of a hos- 
pital or other public institution. 

The strength of the patient must be sustained by a generous 



180 SPECIFIC INFECTIOUS DISEASES. 

allowance of easily digested and nourishing food, preferably 
liquid. Stimulants may be used when indicated by the general 
condition of the sick, and are borne kindly. 

Local treatment is emploj^ed to relieve pain and itching and 
to limit the spread of the disease; it embraces a great variety 
of drugs, not any of them of great value. If wet and cold, 
they are best applied by means of a face mask, made of soft 
linen cloth, with openings for the eyes, nose and mouth, at 
brief intervals wrung out of the solution used. Thompson 
(Pepper's Amer. Text-book) recommends: 

R-. Liq. plumbi subacetatis f5iss. 

Tinct. opii fS ss - 

Aquas q. s. ad. f§viii. — M. 

Sig. — For external use. 

I have had the most satisfactory results from the use of dry 
bran or buckwheat, heated in a spider, and applied to the face 
in bags made of soft linen, frequently changed. Carbolized 
vaseline is also serviceable. 

Attempts to check the spread of the disease by local applica- 
tions generally prove useless. The only measure which at 
times seems of service is painting the surface with contractile 
collodion. Caustics, iodine, the knife, etc., instead of proving 
useful, are a source of additional danger. 

The fever, if high, may be in part controlled by sponging in 
cold water and alcohol and by the use of wet packs. Anti- 
pyretics are discountenanced even by the best authorities of the 
dominant school. Gangrenous areas must be treated with dis- 
infectants, but the practitioner's chief reliance should be con- 
stitutional treatment by the indicated remedy. Abscesses are 
to be poulticed and evacuated early. 

Therapeutics —Belladonna. The eruption is of uniform 
redness, bright, shining, streaked. Congestive type. Charac- 
teristic brain S3^mptoms. — Apis mellifica. The inflamed sur- 
face is rather pale. CEdematous tendency, often involving the 
larynx; stinging, pricking, burning pain; albuminous urine. — 
Rhus toxicodendron. Inflamed surface bright red, angry; 
formation of vesicles; much burning and itching; pain in back 
and limbs, with great general restlessness. After getting wet 
(?). Characteristic typhoid symptoms. — Cantharides. Fol- 
lows Rhus well. Skin intensely inflamed, with tendency to the 
formation of large blisters. Burning-pricking. Dysuria. — 



SEPTICEMIA AND PYEMIA. 181 

Lachesis. Constitutional symptoms prominent. The erup- 
tion is dark, purplish, and the swelling (of the face) great. 
Worse from dark until midnight. Great depression of the vital 
forces, with loquacity, typhoid tendency, dry, red tongue 
which trembles when protruded, etc. Gangrene. — Arsenicum 
album. Great nervous debility, with characteristic restless- 
ness, thirst, and typhoid state. Complete exhaustion of vital 
energy. Cachexia; secondary, long-continued suppuration, 
with sanious, ichorous discharges and burning pain. Gangre- 
nous tendency, with burning, like red-hot coals, in the affected 
parts. 

Other remedies occasionally indicated are: Arnica (swelling 
hot, hard, tense; tired, lame feeling as if beaten; phlegmonous 
form); Camphora (great exhaustion, bordering on collapse, 
even in the early stage); Graphites (tendency to repeated at- 
tacks of erysipelas; recurrence of the disease in distant parts; 
"habitual, often alternating with tettery eruptions"); Sul- 
phur (psoric taint); China (gangrenous tendency); Hepar 
sulphur, (suppurative tendency; will hasten or prevent sup- 
puration); Silica (extensive suppuration, threatening to in- 
volve or involving the hard tissues); Euphorbia, Pulsatilla, 
etc. 

In the beginning: Aconite, Yeratrum viride. Cerebral com- 
plications: Belladonna, Stramonium, Lachesis, Cuprum. 
Formation of pus: Hepar sulph., Silica, Mercurius. Pro- 
tracted suppuration: Arsenicum, Silica, China. Typhoid 
tendency: Arsenicum, Lachesis, Rhus toxicodendron. Gan- 
grenous tendency: Arsenicum, Lachesis, Secale, China. 



SEPTICEMIA AND PYEMIA. 

Septicaemia: A constitutional, generally acute, disease, pop- 
ularly termed blood-poisoning, due to the absorption of vari- 
ous putrid substances into the blood, which are supposed to 
act as ferments and so to change it that it cannot fulfill its 
physiological function. (Foster.) 

Pyaemia: A febrile disease supposed to be due to the absorp- 
tion of pus or its constituents into the blood. It usually fol- 
lows wounds, suppurative inflammation of bone, or the puer- 



182 SPECIFIC INFECTIOUS DISEASES. 

peral state, and results in the formation of secondary abscesses 
in the viscera, joints, and connective tissue. (Foster.) 

Septicaemia and pyaemia are closely related aetiologically 
and clinically. In septicaemia, symptoms of blood-poisoning 
are the more pronounced; in pyaemia, metastatic processes and 
abscesses are conspicuous; both present chills, high fever, pro- 
fuse sweating, haemorrhages, diarrhoea, great prostration of 
the nervous system, affections of the joints, and metastatic pro- 
cesses. 

/Etiology. — The immediate cause is found in the existence of 
certain micro-organisms capable of producing pus. They are: 
(1) The staphylococcus pyogenes aureus, which forms gold- 
yellow colonies; smaller numbers localized produce in the skin 
acne, furunculosis, and subcutaneous abscesses; in the interior 
of the body, suppurations of bones and joints, of the lungs, 
pleura, liver, heart (endocarditis), and kidneys. It abounds in 
the air of crowded rooms. (2) The staph, pyog. albus, which 
forms white colonies. (3) The staphyl. pyog. citreus, which 
forms lemon-yellow colonies. (4) The micrococcus pyogenes 
tenuis, which forms perfectly clear, colonies. (5) The strepto- 
coccus pyogenes, which grows in chains of four, ten, or more, 
members, spreads rapidly, and gives rise to extensive phleg- 
monous processes. These various micro-organisms or their 
products, sometimes both, are introduced through breaks of 
the surface, wounds (parturient or puerperal uterus, etc.), or 
upon the heels of other micro-organisms in the course of spe- 
cific disease (tuberculosis, variola, dysentery, etc.), to cause a 
mixed infection or constitute the terminal link in the chain of 
disease process. (Whittaker.) 

Septicaemia is seen in at least three forms. The lightest of 
these is (1) the fermentation fever, the brief fever which follows 
injuries or operations, the latter with especial frequency when 
the dressings used are such as to cause necrosis of the super- 
ficial tissues. Its symptoms are: fever, not preceded by a chill, 
setting in within a few hours after the injurs' or operation, ris- 
ing rapidly until it reaches a temperature of 103° or 104°, sub- 
siding within one to three days, and not accompanied with se- 
rious constitutional disturbance. 

(2) Sapraemia, due to absorption of toxins from some local 
focus of putrefaction. Symptoms: A chill appears in about 



SEPTICEMIA AND PYEMIA. 183 

twenty-four, or more, hours after the injury or operation, fol- 
lowed by high fever, rising to a temperature of 103° or 104°, 
rapid pulse and, in all save light cases, prostration. Gastric ir- 
ritation, dry, glazed tongue; headache, restlessness and de- 
lirium may be present. Senn (Principles of Surgery) states 
that three conditions must be met here: dead tissue, infection 
of this dead tissue with putrefactive bacteria, and a sufficient 
time to have enabled the putrefactive bacteria to produce a 
toxic quantity of ptomaines. 

(3) Progressive Septicaemia. "The intoxication in this form 
of sepsis is not only caused by ptomaines which are produced 
at the primary seat of infection, but ptomaines are also pro- 
duced in the blood by the microbe which it contains" (Senn). 
These microbes reach the blood through the wall of the blood- 
vessels or through the lymph-channels. Symptoms: Within 
one to four days, rarely later, chilliness or chills set in, fol- 
lowed by moderate fever, which gradually increases and is 
marked by daily remissions and intermissions; the pulse is light, 
compressible, 120, or more, per minute. The constitutional 
symptoms described under sapraemia are present but in an in- 
tensified form. The tongue is red at the margin, and dry and 
brown on the surface; nausea, vomiting and diarrhoea are 
common; prostration is pronounced, with early apathy or de- 
lirium; the face soon becomes haggard and drawn or dirty- 
yellowish in color. Capillary haemorrhages are frequent. 

This form often occurs in the puerperal state and from dissec- 
tion wounds. It is always serious, and death may take place 
in one to seven or eight days. After death the parts at the 
seat of the infection may present no striking changes; the 
viscera may show no extensive lesion; no thrombi or emboli 
are found. The blood, however, is usually of very dark color, 
traces of capillary haemorrhages are abundant, especially on 
the serous surfaces, and there is enlargement and softening of 
the spleen. 

Pyaemia— It is no longer held that this disease is due to the 
actual presence of pus in the blood, but it is attributed to the 
presence of micro-organisms, the streptococcus pyogenes and 
various staphylococci, of which the former are found at the 
seat of the primary lesion and in the metastatic abscesses. By 
coagulation necrosis, thrombi and purulent phlebitis are pro- 



184 SPECIFIC INFECTIOUS DISEASES. 

duced; fragments of these thrombi are carried to distant parts 
of the body, and, containing the elements of infection, they es- 
tablish new centres of infection, i. e. embolic or metastatic ab- 
scesses, at the point of lodgment. Observation teaches that 
in case of external wounds, osteo- myelitis, and in acute phleg- 
mon of the skin, the lungs, heart and kidneys usually become 
centres of suppuration; if the portal system is studded with 
suppurative foci, metastatic abscesses result in the liver; ma- 
lignant endocarditis gives rise to multiple abscesses in the 
spleen, kidneys, intestines, brain, and skin. 

Symptoms. — A severe chill, light in exceptional cases, is fol- 
lowed by high fever, the temperature rising to 103° or 104°, 
and profuse sweating. The chills, followed by fever and sweat- 
ing, may occur daily or every other day; morning remissions 
and evening exacerbations are not infrequent. If the case is 
long-continued, these chills appear at longer intervals and 
with increasing irregularity, but the tendency to sweating is 
pronounced throughout the course of the disease. Loss of ap- 
petite, gastric irritability, and progressive loss of flesh and 
strength are concomitants. Enlargement of the spleen, with 
splenic pain, is common. In cases of unusual severity symp- 
toms of a tj-phoid character develop, probably with coma and 
fatal termination. 

The local symptoms, which greatly modify this picture, vary 
according to the organ or organs involved. 

The chronic form is characterized by chronicity of the course, 
the irregularity and comparative mildness of the chills and 
subsequent fever, and preference for the joints and superficial 
structures. If the patient does not die from exhaustion, he is 
usually left more or less crippled from stiffening or other in- 
juries of the affected joints. 

The prognosis is always grave. 

Diagnosis.— No difficulty is experienced when the disease fol- 
lows injuries, operations, or parturition. Typhoid fever differs 
from pyaemia in its more deliberate onset and in its type. 
Tuberculous troubles, in the absence of well-defined physical 
signs, may readily be confounded with septicaemia, and a clear 
differential diagnosis under such circumstances may be impos- 
sible. Rheumatism has not the successive chills nor the metas- 
tatic abscesses of pyaemia. Malaria has more pronounced 



SEPTICEMIA AND PYEMIA. 185 

periodicity, responds to quinine, and may be recognized by bac- 
teriological examination. 

Exceptionally, Hodgkin's disease, the hepatic fever due to the 
lodgment of gall-stones, and even the fever accompanying rap- 
idly developing cases of cancer, defy attempts at differentiation 
from pyaemia. It may also prove a difficult task to recognize 
pyaemia when arising from such obscure sources as otitis or 
gonorrhoea. 

Some writers describe a septico-pyaemia, a condition in which 
the symptoms of both septicaemia and pyaemia are piesent. 

Treatment.— Prophylaxis consists of asepsis and antisepsis. 
Direct surgical treatment is effective when the seat of primary 
infection is within reach or when the metastatic abscesses are 
accessible; in such cases antiseptic washes, the use of a dilu- 
tion of Calendula in water, opening and thorough cleansing 
of the abscesses formed, are obviously in place. In addition, 
the strength of the patient must be sustained by proper, nour- 
ishing diet and stimulants. 

Therapeutics. — In selecting the remedy, cognizance must be 
taken of the primary cause, the constitutional affection, and 
the local manifestation of the disease. 

To be truly curative, the remedy must be capable of reach- 
ing that general systemic depravity which belongs to the con- 
dition. Hence the great value here of Arsenicum album, 
Chinin. arsen.,Baptisia, Phosphorus and China, remedies of 
far-reaching power -whose symptomatic indications need not 
be here enumerated. 

Lachesis has to a remarkable extent the power to produce 
extreme prostration of the nervous system, to disorganize the 
blood, and to affect suppurative processes. Hence, its applica- 
bility to cases of pyaemia with typhoid tendency. It is very 
useful when the liver is invaded and hepatic abscesses threaten 
or exist. In puerperal pyaemia, and in all cases involving the 
intestinal tract or the pelvis, it is one of the most prominent 
remedies. Rhus toxicodendron, the Mineral Acids and 
Arnica are also to be consulted. Phosphorus is valuable when 
lung or liver complications are present. 

Hepar sulphur, and Silica are useful by virtue of their close 
relation to the suppurative process. Silica covers to a nicety 
the symptoms most frequently found in pyaemia as a distinct- 



186 SPECIFIC INFECTIOUS DISEASES. 

ive state, including the nervous tension, the hectic fever and 
profuse sweating, offensive discharges, glandular swellings, 
with tendency to suppurate, sensitiveness to cold, etc. 

The simple "fermentation fever" which follows injuries or 
operations rarely requires medication; when remedies are de- 
manded, the indications will almost surely be met by Aconite, 
Arnica, Gelsemium and Veratrum viride. 



ANTHRAX. 

Synonyms: Malignant pustule. — Contagious carbuncle; Char- 
bon. — Mycosis intestinalis. 

An acute infectious disease, occurring primarily in animals, 
especially in sheep and cattle, due to infection with the bacillus 
anthracis (Pollender, 1849). The bacilli anthracis are thread- 
like bodies from two to ten times as long as the diameter of a 
red blood-corpuscle; the}' multiph' by fission, and set free 
spores which possess remarkable tenacity of life, resisting gas- 
tric digestion and, for several minutes, a temperature of 212° 
F. They occur in the blood, milk and tissues of animals who 
have died from anthrax, in the pastures occupied by diseased 
animals, and probably in the earth. The disease is "the most 
wide-spread of all infectious disorders;" but is comparatively 
infrequent in America. 

In man, anthrax is the result of direct inoculation, through 
the skin or intestine, with the infectious agent. Thus, herders, 
butchers, and others brought into contact with animals suffer- 
ing or dead from anthrax, are easily inoculated at the seat of 
even a slight abrasion or wound. Persons -who in the pursuit 
of their business handle the carcasses, hides or hair of infected 
animals, as do the buyers of hides and hair, hair-pickers and 
assorters, rope-makers, or laborers in factories where these 
articles are used, are often affected. It is probable that flies 
and other insects frequently carry the infection. Intestinal in- 
fection usuall}' results from eating the meat or drinking the 
milk of infected animals. 

Anthrax occurs in two forms, the external (malignant pus- 
tule) and the internal (intestinal mycosis). 



ANTHRAX. 187 

Malignant pustule is seen in some exposed part of the body, 
as the arms, hands, or throat. A few days, from three to seven, 
after the infection, a vesicle appears at the seat of the infection, 
which rapidly increases in size, becomes excoriated, and soon 
assumes a dark-bluish, black color. Diffuse hard swelling and 
redness of the surounding parts takes place promptly; sec- 
ondary vesicles are formed, with rapidly increasing and exten- 
sive swelling of the parts, the swelling and soreness soon in- 
volving the neighboring lymph-glands. Bright-red lines radi- 
ate from the pustule. High fever and great prostration accom- 
pany this condition. Recovery takes place with decline of the 
fever, sloughing of the parts, and healing of the sore. In case 
of a fatal termination the constitutional symptoms increase in 
intensity, soon overshadowing the local affection, and the pa- 
tient dies from intestinal complications or with symptoms of 
profound prostration of the nervous system, as delirium, 
stupor, coma. In other cases an intense oedema, chiefly seen 
about the head, hands and arms, appears in place of the pus- 
tule, rapidly developing extensive gangrene, with profound 
constitutional involvement and fatal termination within a few 
days {malignant anthrax oedema) . 

Intestinal anthrax or intestinal mycosis is characterized by 
symptoms of severe intestinal disorder, as vomiting, diarrhoea 
(at first usually painless), moderate fever, and pain in the legs 
and back. The patient soon complains of dyspnoea and a 
sense of great oppression in the chest, followed by restlessness, 
coldness of the nose and extremities, rapid and small pulse, 
livid appearance of the surfaces, often haemorrhage from the 
mucous membrane, and spasms and convulsions. The fever is 
rarely high, and a subnormal temperature may supervene. 
Utter prostration of the nervous system results, and death 
follows in a few days. In some cases small phlegmonous sores 
or carbuncles have been observed during the course of the dis- 
ease. The existence, occasionally, of a pustule on the hand or 
some other exposed part of the body, for a considerable period 
prior to the appearance of the constitutional disease, argues in 
favor of general infection from a local disease. 

The so-called Wool-sorter's Disease is a mild form of intestinal 
mycosis with pulmonary complications, as: rapid breathing, 
pain in the chest, cough, and signs of bronchitis. 



188 SPECIFIC INFECTIOUS DISEASES. 

In exceptional cases both forms are seen simultaneously in 
the same patient, malignant pustule being accompanied with 
intestinal mycosis. 

Fatal cases exhibit after death catarrhal inflammation of the 
intestinal mucous membrane, with dark, infiltrated hasmor- 
rhagic spots, a trifle larger than a dime, situated in the small in- 
testine and in the upper colon. The spleen usually is dark, con- 
gested and moderately large. The lymph glands are swollen 
and ecchymotic spots may be found in the kidneys, brain and 
serous membranes. Anthrax bacilli abound in the affected or- 
gans and in the lumen of the blood vessels. 

The diagnosis is easy when the cause of the disease is apparent; 
otherwise it may be difficult, especially in the early stage of the 
intestinal form. A demonstration of the existence of the an- 
thrax bacilli may be necessary to determine the nature of the 
affection. 

Treatment. — Cauterization, incision, and excision of the pus- 
tule is objectionable. "It should be borne in mind that such 
manipulations ma}' easily contribute to a local extension of the 
anthrax poison" (Struempell). Osier recommends destruction of 
the site of inoculation by the caustic or hot iron, with sprinkling 
of powdered bichloride of mercury over the exposed surface, and 
the subcutaneous injection of solutions of carbolic acid or bi- 
chloride of mercury, two or three times daily, at various points 
around the pustule to preA^ent the local development of the 
bacilli about the site of inoculation. Struempell merely places 
the limb in a suitable position and applies an ice-bag over the 
diseased spot. The use of disinfectants and charcoal poultices 
is proper. 

In the early stage of the local disease Belladonna may be 
indicated by the bright redness of the parts, the throbbing pain, 
and the erysipelatous tendency'. — Lachesis has the bluish color 
of the anthrax pustule, with intense burning pain in the parts, 
relieved by the use of cold water. There is profound depres- 
sion of the nervous system. It covers the tendency to haemcr- 
rhagic effusions and to the typhoid state. — Arsenicum. The 
pain is burning, as from a live coal on the part; rapidly devel- 
oping and intense prostration, with small, irregular, rapid 
pulse; diarrhoea; collapse; hasmorrhagic tendency; typhoid 
state. — Apium virus. Predominance of erysipelatous and cede- 



ASIATIC CHOLERA. 189 

matous symptoms. — Rhus toxicodendron. Characteristic 
restlessness, erysipelatous tendency, typhoid state. — Anthra- 
cinum is recommended by Raue when the burning pain is vio- 
lent and not relieved by Arsenicum; cerebral symptoms, gan- 
grenous destruction of the affected tissues, blood-poisoning. 
If the immediate danger has passed and sloughing takes 
place, with promise of recovery, Hepar sulphur., Silica, 
China and other remedies of this class are indicated. 



ASIATIC CHOLERA. 

An acute, infectious disease, usually occurring as an epidemic, 
due to the presence of the comma bacillus of Koch, and char- 
acterized by violent purging and tendency to collapse. 

"The disease is due to a specific virus, namely, a germ which 
enters the body through the alimentary canal and attacks the 
small intestines, where it develops ptomaines, which, on being 
absorbed into the system, produce constitutional symptoms. 
The disease is propagated by fomites and by direct contact 
with the stools. The chief agent for its dissemination is con- 
taminated drinking water. The contagion multiplies with ex- 
treme rapidity both inside and outside the body, and it thrives 
especially in warm, moist putrefactive organic matter." 
(W. Gilman Thompson.) 

The existence of the comma haccillus in cases of Asiatic 
cholera was demonstrated by Koch in 1884. It occurs in no 
other disease. Inoculation of guinea pigs and dogs has pro- 
duced in them a true type of Asiatic cholera. Koch's bacillus 
is shaped like a comma or curved rod, sometimes like the letter 
S, is about one-half the size of the tubercle bacillus, but thicker, 
and is endowed with motion. It perishes after thorough freez- 
ing, is sensitive to acids, especially lemonade (Uffelmann), and 
is quickly killed by carbolic acid, corrosive sublimate, etc. It 
thrives abundantly in foul, contaminated water, and has been 
found in large numbers in wells and streams contaminated by 
the washing of linen used by persons sick of cholera. It occurs 
early and in great numbers in the intestine of choleraic 
patients, in the stools, especially in the rice-water discharges, 



190 SPECIFIC INFECTIOUS DISEASES. 

rarely in the vomit. Examinations, post-mortem, show that 
in rapidly fatal cases it has not invaded the intestinal walls; in 
more protracted cases the follicles and deeper tissues contain 
large numbers of the bacilli. 

It is generally conceded that contaminated water is in the 
great majority of cases the medium through which the bacillus 
gains entrance to the human bod} T . The history of recent epi- 
demics in India, England, and Germany has amply demon- 
strated this fact, and has also proved that a generous supply 
of pure water will in a short time stamp out the disease. The 
importance of maintaining the purity of water is evident from 
the constant and varied use made of it, not only for drinking 
purposes, but in the preparation of food in the kitchen (as the 
washing of vegetables preparatory to cooking). Milk is fre- 
quently diluted with water, and may thus become polluted and 
a disease carrier. The same applies to the washing of dishes, 
linen, etc. 

In some cases the germ undoubtedly is inhaled, but it is con- 
ceded that, to do mischief, it must reach the intestine, in whose 
alkaline contents it flourishes. 

Pettenkofer applies his subsoil theory to the propagation of 
cholera, as he does to t3'phoid fever, and maintains that a 
moist, porous soil, contaminated with organic matter, such 
as sewage, especially in dry weather following a very wet per- 
iod, in other words: conditions which are favorable to putre- 
factive fermentation, eventually contaminating wells and 
streams or rising into the atmosphere as miasma, are quite 
sufficient to account for outbreaks of the cholera. A study of 
the epidemic in Calcutta, India, Buda Pesth (1886 and 1873), 
and in Munich (1873) seems to establish the soundness of this 
view. 

Among predisposing causes those constitutional states are to 
be mentioned which lower vitality and thus lessen the power 
of resistance to any infection or miasm; ill health, intemper- 
ance of am>- kind and the weakness of old age belong to these. 
Insanitary conditions, foul air, filth, improper food, insuffi- 
cient and dirt}^ clothing, are also powerful predisposing fac- 
tors; persons living under such surroundings furnish so large a 
proportion of the victims that cholera might well be called a 
filth disease. Excessive fear, by its depressing influence, may 



ASIATIC CHOLERA. 191 

become an important predisposing cause. Age affords no 
protection, but the young are least liable. The season of the 
year in which cholera prevails most extensively in Europe and 
in America is late summer and fall; the comma bacillus thrives 
during hot weather and does not bear cold; hence the relief 
which invariably comes with the approach of winter. As to 
locality, preference is shown for a low altitude and for places 
situated on the level of the sea. The disease rarely occurs on 
elevated plateaus. 

The contagion does not spread by the air, but by direct con- 
tact. It follows the line of human travel, preferably water- 
ways. It may be conveyed from person to person, chiefly by 
fomites; also to distant places, as in mail-matter. Contact 
with the stool of persons sick with cholera constitutes its chief 
mode of propagation. 

Morbid Anatomy. — The changes, post mortem, are not char- 
acteristic. Milles, half an hour after the death of a person 
from cholera, found that the small intestine was of a rose-red 
color and distended as if paralyzed. It contained a typically 
clear stool. The mucous membrane was swollen and denuded 
of its epithelium. The follicles were filled with epithelial detri- 
tus and comma bacilli, and their orifices appeared as red spots. 
Comma bacilli were also discovered in the subepithelial tissue. 
Rigor mortis is marked, sets in early, and continues long. 
Muscular fibrillations are often sufficiently pronounced to cause 
movements of the jaws, eyelids, fingers, or extremities; the in- 
ternal organs are drained of blood and liquids; the blood, espe- 
cially in the right ventricle, is dark, and may be of the con- 
sistency of tar. The spleen is small, the heart flabby, the lungs 
collapsed. There is frequently a post mortem elevation of the 
temperature. 

Symptomatology. — Clinically the disease is divided into 1) 
the stage of incubation; 2) the preliminary diarrhoea; 3) the 
algid stage; 4) the stage of reaction. Of these, the stage of incu- 
bation is not -well defined and may continue for several (two 
to five) days. 

The. preliminary diarrhoea is characterized by more or less per- 
sistent colicky pains, with diarrhoea, vomiting, headache, men- 
tal depression, and some degree of apprehensiveness, possibly 
fever. Occasionally these symptoms set in suddenly; again 



192 SPECIFIC INFECTIOUS DISEASES. 

they develop gradually, a faint uneasy feeling in the bowels 
commonly first arresting the attention of the patient. The 
tongue, at first, is pale and moist; later it becomes dry. It is 
worthy of note that the alvine discharges even in this stage 
contain large numbers of the specific bacilli, and must therefore 
be handled with extreme care. 

The algid stage (stage of asphyxia, stage of collapse). The 
characteristic symptoms are those of rapidly increasing diar- 
rhoea, with profuse vomiting, intense thirst, excessive restless- 
ness, cramps in the legs and feet, and collapse. 

The diarrhoea, from the beginning of this stage, rapidly in- 
creases, and is accompanied with griping, sometimes tenesmus, 
but oftener with a sensation of great faintness in the abdomen. 
The stools are alkaline, odorless, possibly of a faint "meaty" 
odor; very thin, at first yellow, then of a turbid grayish-white, 
like rice-water, frequently containing flakes of mucus and gran- 
ular matter, sometimes traces of blood. Later in the stage of 
collapse the evacuations may assume a dark appearance and 
become very offensive. The stools are expelled with a gush and 
in such quantities as to drain the blood. 

In some cases a temporary sense of relief is experienced after 
the stool. 

Vomiting becomes severe a few hours after violent diarrhoea 
has set in ; it may follow at once. It is copious, usually with- 
out effort, gushing from the mouth with sufficient force to 
spurt several feet from the body, and often incessant. Thirst 
becomes inappeasable as the system is drained of its liquids; 
the tongue is white, but dry; uncontrollable restlessness and 
intense anxiety supervene. 

Cramps in the legs (calves) and feet are severe and may cause 
much suffering; they do not appear suddenly, at a stroke, as in 
tetanus, but come on gradually and grow worse continuously. 

Symptoms of collapse now appear, shown in the ashy-gray 
face, sunken eyes, ghastly features, pinched nose, coldness of 
breath, huskiness of voice, and cold, wrinkled, clammy, bluish 
condition of the skin and extremities. The pulse becomes more 
and more rapid and feeble. The secretion of urine is sup- 
pressed. The temperature sinks, and the mouth and axilla 
may register several degrees below the normal, while in the 
rectum there is shown a temperature of 103° or 104°. 



ASIATIC CHOLERA. 193 

The excessive loss of the fluids of the body results in thicken- 
ing of the blood and in the arrest of the secretions, notably of 
saliva and urine; sweating continues. Death occurs from 
asthenia or asphyxia, in rare instances preceded by coma. 

This stage may not be preceded by the more common prelim- 
inary diarrhoea, but set in suddenly and with intense violence; 
in cases tending to a rapidly fatal termination death may take 
place in two or three hours; more frequently the algid stage 
lasts from twelve to twenty-four or thirty-six hours. Again, 
death may occur before purging sets in {cholera sicca). 

Stage of Reaction. — The patient having passed safely 
through the dangers of this condition, recovery is ushered in 
by a general amelioration of symptoms. The intestinal uneasi- 
ness and colic improves; vomiting, cramping and ravenous 
thirst gradually cease; the stools occur at longer and increas- 
ing intervals, assume firmer consistency and natural color and 
odor; with it, there is return of bodily warmth, increasing 
steadiness and vigor of the heart's action, and reappearance 
of thcurinary secretion. 

Complications, however, may arise. Diarrhoea may return 
and result fatally. At times the epithelial surface of the intes- 
tine has been denuded to an extent which greatly retards or 
endangers recovery. In the former case more or less pro- 
tracted hemorrhagic tendency is observed; in the latter, a 
typhoid state (cholera typhoid) may develop, due to sepsis 
from absorption, with dry tongue, delirium, coma, and death; 
or, if not fatal in termination, there may develop a low, pro 
tracted fever of the typhoid type, with tedious recovery. Both 
forms are accompanied with eruptions, as erythema, roseola, 
urticaria, first on the forearm and wrist, later on the face and 
body, but rarely extensive. In other cases symptoms of 
ursemic poisoning may show themselves, with profound ner- 
vous prostration, delirium, convulsions and death. 

Forms of Cholera. — An epidemic necessarily presents a great 
variety of forms. The term Cholerine is used to designate the 
mild form, resembling the cholera nostras which prevails dur- 
ing the hot season of temperate climates; it consists of an ac- 
tive diarrhoea with more or less vomiting, and is dangerous 
to the public health chiefly because of indifference of the public 
to the fact that the stools of such patients contain all the ele- 
13 



194 SPECIFIC INFECTIOUS DISEASES. 

ments of danger to others which belong to the most serious 
form of the disease. Cholera sicca has been described; it fur- 
nishes a large number of fatal cases. In still more serious cases 
the poison completely overwhelms the system and the patient 
dies comatose within a few hours. 

Complications and Sequelae are chiefly such secondary affec- 
tions as result indirectly from the exhausted, low state in 
which the convalescent is left. To the typhoid complications 
alread}' mentioned, there may be added pneumonia and renal 
affections, especially consecutive nephritis. Various eruptions, 
furunculosis, abscesses, bed-sores, diphtheritic inflammations of 
the mucous membrane, particular^ of the throat and genitals, 
parotitis, weakness of the digestive organs and of the circula- 
tion, persistent cramps in the legs and arms and general irrita- 
bility and weakness of the nervous s} r stem are among the more 
common sequels. 

Duration. — The duration of an attack of cholera varies from 
a few hours to several daj^s, according to the form of the dis- 
ease; if fatal, the average case usually terminates in two or 
three daj^s. The stage of reaction may be prolonged indefi- 
nitely. The duration of an epidemic rarely exceeds one month 
in a stated locality. 

Diagnosis.— Asiatic cholera so closely resembles clinically the 
cholera nostras of the temperate climate that a positive differ- 
ential diagnosis can only be made by bacteriological examina- 
tion. Cases of poisoning with arsenic, corrosive sublimate, 
certain fungi, and ergot closely resemble cholera. 

Prognosis.— The mortality ranges from 30 to 80 per cent.; 
during the epidemic at Hamburg (1892) it was 43 per cent. 
Low temperature, marked cj^anosis, and rapidly developing 
collapse are very unfavorable symptoms. During an epidemic 
the mortalit}^ is greatest in the earl} r and middle period. 

Treatment.— As stated by Rohe (Text-book of Hygiene, 
1895), prophylaxis comprises such measures as will prevent 
the admission of the cholera poison into a community, arrest 
the development of the poison after its introduction, and reduce 
the individual susceptibility to attack. 

To accomplish the first, as applied to America, quarantine 
at sea is undoubtedly most effective. Detention of suspected 
passengers, and disinfection of soiled linen under dry heat 



ASIATIC CHOLERA. 195 

(250° F.), covers the necessities of the case as demonstrated in 
the harbor of New York in 1893. 

To arrest the development of the poison after its introduc- 
tion, local sanitation must be vigorously enforced. Absolute 
cleanliness of yards, dwelling houses, soil and water must be 
secured. The bearing of polluted soil upon the disease has been 
discussed, and the necessity of maintaining a supply of pure 
water for all domestic purposes has been shown. It is always 
well to boil water and then cool it. Filtering alone is not suffi- 
cient. It is obvious, also, that self-preservation on part of a 
community demands not only the energetic enforcement of 
these precautions, but prompt, intelligent and free medical ser- 
vice to the poor, and, if necessary, the establishment of free hos- 
pitals, both for the purpose of aiding the sick poor and of in- 
suring the practice of such precautions as will lessen the dan- 
ger of spreading the infection broadcast. Isolation of all the 
sick and thorough disinfection in every direction are, of course, 
important. 

To reduce individual susceptibility to the disease, special 
pains must be taken to use only pure water for all domestic 
purposes, especially for drinking; errors of diet must be 
avoided, and any derangement of stomach or bowels must re- 
ceive attention. Undue fear is a depressant, and thus becomes 
a predisposing cause of the disease. Mental worry, overwork, 
exposure, etc., are to be shunned. 

Strong lemonade or a solution of 15 drops of dilute sulphuric 
acid in a glass of water, sweetened, is highly recommended; it 
has been demonstrated that the comma bacillus cannot live in 
acid solutions. Copper and arsenic {vide infra) are also valua- 
ble prophylactics. 

A person once sick with cholera, isolation, perfect rest, and 
disinfection of stools and vomited matter are imperatively de- 
manded. The latter may be accomplished by mercuric chloride, 
carbolic acid, and chloride of lime. The first is the most effi- 
cient, and a solution of 1:1000, added to an equal proportion 
of the discharges, will render them harmless after an exposure 
of not less than two hours. To prevent accidents resulting 
from having so dangerous a solution about the premises, it 
should be colored with permanganate of potash or sulphate of 
copper. In water-closets provided with lead pipes the mercuric 



196 SPECIFIC INFECTIOUS DISEASES. 

chloride solution cannot be used; chloride of lime (1:100) or 
carbolic acid (1:20), if reliable, may be employed; Rohe recom- 
mends Little's soluble phenyle (1:50), which readily mixes with 
water; it is both a disinfectant and effective deodorizer. 

After recovery or death, clothing, bedding, utensils which 
were used in the sick room, and the room itself, including the 
walls, must be thoroughly fumigated, treated with mercuric 
chloride wherever possible, and freely exposed to the air. 

The patient requires close attention. His thirst may be grat- 
ified with bits of broken ice, champagne, carbonized water, 
lemonade, hot coffee. The application of external heat will 
prove grateful; it may be applied to the abdomen by means of 
cloths wrung out of hot water, blankets, etc.; jugs of hot 
water along the spine and sides of the body and at the feet, or 
hot sand-bags, add greatly to the comfort of the sick one. 

The cramps may be somewhat relieved by heat and by brisk 
rubbing of the parts with the bare hand. Irrigation of the 
whole bowel with a hot one per cent, solution of tannic acid or 
with a mercuric bichloride solution (1:100000) has its warm 
advocates. Cantani has had good results from the use of the 
hypodermic clyster, by means of which he injects at either loin, 
behind the ribs, a solution of common salt, one drachm to 
a quart of distilled water, to which has been added fourteen 
grains of carbonate of soda. The skin is punctured with a fine 
trochar, the trochar withdrawn, the tube of a fountain syringe 
introduced, and the fluid allowed to flow; gentle massage stim- 
ulates its absorption. This treatment, variously modified by 
different practitioners, has met with much favor, and excellent 
results are claimed for it; it supplies to the blood liquids 
withdrawn by the copious stools, and it antidotes, to a certain 
extent, the poisonous action of the toxins. Collapse is met by 
the use of stimulants by the mouth or hypodermically. Cam- 
phor is very useful. The kidneys may be stimulated, espe- 
cially during convalescence, by hot baths and copious drafts of 
hot water. The diet during convalescence should be fluid and 
nutritious, as soup, milk, broths, gruels, egg in milk. 

Therapeutics. — The remedies which have proved most reli- 
able in past epidemics are Camphora, Cuprum, Arsenicum and 
Yeratrum album. 

Camphor has made a peculiarly brilliant record, both as a 
prophylactic and as a remedy. 



ASIATIC CHOLERA. 197 

Its value as a prophylactic has been tested in every epidemic 
of cholera since Hahnemann first suggested it; experience has 
shown that drop-doses, three or four times daily, of a saturated 
solution of the gum camphor in alcohol (Rubini's Camphor), 
is most effective. No candid observer can call into question 
the reliability of the testimony offered on this point. In the 
first stage Hahnemann advised the instant use of camphor on 
the appearance of cholera symptoms, one drop on a lump of 
sugar, every five minutes; in severe cases he also recommends 
rubbing the palms of the hands and other parts of the body 
with a solution of camphor. If the patient is unconscious or 
unable to swallow, he gives an enema of two teaspoonfuls of 
camphor in half a pint of warm water; he also advises the 
evaporation of camphor on a hot iron in the room. In the 
stage of collapse camphor again is invaluable, and should be 
given in five-drop doses on sugar; in very grave cases, ten 
drops may be given every fifteen minutes. Cigliano, of 
Naples, and many others, like the late Dr. J. P. Dake (see 
Arndt's System), who have had extensive clinical experience 
with Asiatic cholera, claim for camphor remarkable results, 
even a mortality not to exceed one per cent. — Cuprum is 
credited with prophylactic powers not only by homoeopaths, 
but, after the epidemic in France (1884), by Claude Bernard, 
Charcot, and others as eminent. It was observed that work- 
ingmen in copper foundries or in shops filled with copper dust 
were almost exempt from the cholera when the disease was 
raging all around them. For purposes of prophylaxis the salts 
of copper have been used in doses of from fifteen to twenty cen- 
tigrams a day; the lower triturations of the metal are effective, 
insoles of a thin sheet of metallic copper, worn between the 
boot and stocking, have been found to answer the same pur- 
pose. Hahnemann considered Cuprum indicated in the second 
stage of the disease, to be given at intervals of half hour or 
hour. Indications: Very painful clonic spasms in different 
parts of the body; great pressure in the pit of the stomach, 
worse from contact; constriction of the chest; great thirst; 
gurgling noise when drinking; anxiety; cold face, blue lips; 
coldness all over; urine suppressed. Colic is usually severe; 
there are no aggravations from drinking; in fact, cold water 
relieves for a time both vomiting and diarrhoea. — Arsenicum. 



198 SPECIFIC INFECTIOUS DISEASES. 

Arsenicum has made an excellent record. The pathogenesy of 
the remedy presents a striking similarity to the clinical picture 
of cholera, and its exhibition, when indicated, has been so sat- 
isfactory (as, for instance, in the recent epidemic at Hamburg), 
that man}' practitioners look upon it as a very sheet-anchor in 
the treatment of cholera. The s\^mptoms commonly present 
are: Great restlessness and anguish, increasing toward night; 
fear of death; pale, distorted face, with dark blue rings around 
the eyes; great thirst, with intolerance of cold water, even in 
small amounts. Violent burning pain in the stomach, worse 
from vomiting, which is frequent. Great oppression and con- 
striction of the chest; voice hoarse, husky; coldness and bluish 
appearance of the extremities; skin wrinkled, dry, cold, 
clammy, sticky; objective coldness, subjective heat; cramps in 
the calves of the legs. Hippocratic countenance. During the 
Hamburg epidemic the higher attenuations failed to relieve; 
the 3d and 4th dec. cured promptly. The arsenite of copper 
has been successfully used.— Veratrum album. Veratrum has 
violent vomiting and purging, with constant desire for cold 
drinks; copious, watery stools, without odor, mixed with 
white flakes; icy coldness of the body, of the tongue, of the 
breath; loss of voice; anguish in the chest; violent colic, with 
great sensitiveness of the abdomen to touch; severe cramps in 
the calves of the leg. Cold sweating. Expression of deathly 
anguish in the features. 

In the preliminary diarrhoea and in diarrhoea occurring during 
a cholera epidemic the following are to be consulted: Ipecacu- 
anha: Vomiting most prominent, chiefly of sour fluid. Colo- 
cynthis: Great colic; frequent watery diarrhoea; cramps in the 
calves; vomiting of ingesta, later of green substance. Croton 
tiglium: Violent vomiting, gushing out of yellow, watery dis- 
charges mixed with whitish flakes; rumbling, griping in the 
bowels, later burning in the anus; evacuations brought on by 
motion and effort of any kind; great exhaustion. Jatropha 
curcas: Easy vomiting of large quantities of water or of a 
substance resembling the white of egg; gurgling noise in the ab- 
domen, sounding as though a bottle were emptied; watery 
stools, gushing forth like a torrent; abdomen drawn in; cold- 
ness of the body; cold, sticky perspiration; pulselessness. 

Podophyllum, Ricinus, Iris, and others, may have to be con- 



DYSENTERY. 199 

suited. Rhus toxicodendron and Bryonia are frequently sug- 
gested by the presence of typhoid symptoms (cholera 
typhoid). Hydrocyanic acid is to be considered when there 
is a condition of extreme prostration and a tendency toward 
asphyxia. Secale cornutum has proved useful in exceptional 
cases. The vomiting has ceased, but diarrhoea continues; aver- 
sion to heat or to being covered, though the surface is icy cold; 
numbness and pricking in the fingers and toes; the fingers 
spread wide apart. 



DYSENTERY. 

This term covers a group of symptoms widely differing in 
their aetiology and pathology, and constituting a state char- 
acterized chiefly by intestinal flux with discharges of mucus, 
blood, pus, and tissue-debris, accompanied by severe colicky 
pain and tenesmus. 

^Etiology. — Dysentery is essentially a disease of the tropics, 
where it is both endemic and epidemic. It is, however, common 
in the temperate zones and occurs sporadically in the United 
States, where it often assumes epidemic form, at times with a 
high rate of mortality. In the Southern states, especially in 
southern cities, cases of dysentery exist constantly, and epi- 
demics are frequent and severe. 

The disease is more liable to occur during the hot season of 
the year, in late summer and autumn. It spares no age, sex, 
or race, but shows some preference for adult males, who, as a 
class, are more subject to predisposing influences. Among the 
latter may be mentioned sudden changes of temperature; mala- 
rial conditions; the use of impure, especially stagnant, drinking 
water or of water contaminated with the stools of dysenteric 
patients; indigestion, particularly indigestion arising from the 
use of bad food or unripe fruit; severe constipation; unhygienic 
surroundings; great mental depression. It is possible that to 
this latter cause is due, nearly as much as to bad surroundings 
and improper food, the prevalence of dysentery among prisoners 
of war and soldiers. 

The specific cause of dysentery has not yet been determined, 
but its ready appearance, in epidemic form, among armies ar- 



200 SPECIFIC INFECTIOUS DISEASES. 

gues strongly in favor of the existence of an infectious agent. 
The amoeba coli, "a unicellular, motile body, measuring twenty 
to fifty micromillimeters in diameter, and consisting of granu- 
lar protoplasm which contains a nucleus and several vacuoles" 
(Pepper), first described by Lamb (1859), and since then 
studied by other observers, is constantly present in the epi- 
demic form of the tropics. Various other organisms have, 
however, also been found. The preponderance of evidence 
tends to prove that dysente^ is not contagious. 

Clinical History. — Since the term "dysentery" covers a group 
of sy mptoms which differ essentially in cause and expression, 
a division into distinct forms is natural and practical. The 
clinical forms recognized are: the sporadic, epidemic, and 
chronic. The pathological forms are: the catarrhal, the 
amoebic, the diphtheritic or pseudo-membranous, the chronic. 

The catarrhal form. — The large intestine, almost exclusively, 
is the seat of the affection, the lower ileum being occasionally 
involved. There are found areas of injected, swollen mucous 
membrane, covered with tenacious, blood-tinged mucus, some- 
times containing pus. Extravasations of blood, punctate or dif- 
fuse, are frequently present. There is enlargement of the solitary 
follicles, from the size of a pin-head to that of a pea, standing 
out prominently (acute follicular colitis, follicular dysentery). 
If severe, there is follicular ulceration and necrosis of tissue at 
the apices; this process may extend, involving the surrounding 
tissues, penetrating deeply, and presenting numerous ulcers 
with undermined walls and small openings, surrounded by cel- 
lular infiltration and honey-combing of the entire mucous layer; 
in these cases necrosis and sloughing of intervening tissues may 
become extensive. 

Symptoms. — Usually some slight loss of appetite and uneasi- 
ness in the bowels, rarely chill or chilliness, possibly moderate 
fever, are the only premonitory symptoms. There is slight 
diarrhoea, at first painless, gradually increasing, which after 
thirty-six to forty-eight hours is characterized by severe griping, 
straining and tenesmus. The evacuations from the bow r els 
increase in frequency and soon present the characteristic 
features of dysentery. 

The constitutional symptoms are comparatively mild in the 
majority of cases; there is little fever, the temperature rang- 



DYSENTERY. 201 

ing trom 102° to 103°; there may be nausea and vomiting, 
but often there is no gastric disturbance, and food is taken 
with relish and retained. Thirst is nearly always present, and 
often is excessive. The tongue, at first furred and moist, later 
becomes red and glazed. The stools at first contain mucus and 
blood, mixed "with small, hard lumps of faecal matter (scybala); 
they rapidly increase in frequency and assume a glairy, gelati- 
nous appearance, still containing blood. There is almost con- 
stant urging, with intense, exceedingly painful straining and 
tenesmus, usually relieved, for a short time only, after a stool; 
the number of stools had during the twenty-four hours is esti- 
mated at from fifteen to two hundred, and the amount passed 
is entirely out of proportion to the pain connected with the 
act. 

At the end of the week, or in exceptional cases earlier, the 
stools, become less frequent and opaque in appearance; shreds 
of mucus and tissue-debris, grajdsh brown, are passed; soon 
they assume a greenish color and become mushy in consist- 
ency; then the admixture of blood and mucus grows less, the 
amount of faecal matter increases, and recovery takes place. 

Such an attack lasts from eight to ten days, sometimes much 
longer, even to four, or more, weeks. The prognosis is favor- 
able, save in quite young children. Complications are rare. 
Recovery usually is perfect, but the disease may assume a 
chronic form, especially when the attack has been prolonged. 

Amoeboid {or Tropical) Dysentery.— -The dysentery of the 
tropics, particularly fatal when occurring in epidemic form, 
and characterized by the presence of the amoeba coli (amoeba 
dysenteriae). 

The parts involved are the large intestine, preferably the 
caecum, hepatic and sigmoid flexures, and the rectum, some- 
times the lower ileum. There is infiltration of the submucous 
tissue which results in a round, well-defined elevation of the 
parts above the general level of the intestinal mucous mem- 
brane, followed by sloughing of the latter. The ulcer formed 
is round, oval, or irregular, with ragged, undermined, infil- 
trated edges; the floor is grayish-yellow, and may be formed 
of the submucous, muscular, or serous coat, according to the 
depth of the parts involved; the aperture is much smaller than 
the base of the ulcer. These ulcers frequently are connected by 



202 SPECIFIC INFECTIOUS DISEASES. 

sinuous openings, covered with healthy mucous membrane. If 
the disease is extensive, the entire gut is thickened, and may be 
fairly riddled with ulcerations. A notable feature is the small 
amount of pus present. Sloughing occurs and in severe cases 
may be very extensive, especially so when there is pseudo-mem- 
branous formation, as is not infrequent. Extension of the 
ulcerative process depends upon progressive infiltration of the 
connective tissue-layers and necrosis of overlying structures. 
Healing takes place by fibrous tissue formation at the bottom 
and edges of the ulcer, and, in rare cases, this may give rise to 
partial and irregular stricture of the bowel. 

Secondarily, abscesses in the liver may form, characterized 
by the presence of amoebae and by the same relative absence 
of pus noted in the intestinal lesion. These abscesses are 
more frequently seen on the convex surface near the attach- 
ment of the liver and diaphragm or on the concave surface 
over the bowel. Sometimes extension, by continuity, into 
the right lung has been observed. If multiple, the abscesses are 
small. Their walls usually are soft and necrotic; if old, hard 
and fibrinous. 

Symptoms. — The onset may be sudden, particularly in very 
severe cases; more frequently the attack develops gradually. 
Many of the symptoms described under catarrhal dysentery 
may be absent, as: fever, pain, tormina and tenesmus, even 
mucus and blood in am*- considerable quantities; again, all 
these may be present. A moderate degree of abdominal pain 
and tenesmus is quite common in the early stage, but will 
probably disappear later on. The characteristic of this form 
of d}'sentery lies in the fluidity of the stools, of which from six 
to twelve are passed daily for a period of from six to twelve 
weeks; these stools are yellowish-gray in color and commonly 
contain a slight admixture of mucus and blood. 

The disease runs an irregular course and presents frequent 
exacerbations and remissions. 

The prognosis is serious. As stated, the duration of the dis- 
ease, even without complications, covers a period of from 
two to three months and involves such dangers as arise from 
great muscular exhaustion, anaemia, relapses, secondary hepa- 
tic abscesses, and a decided tendency to chronicity. The rate 
of mortality is high, death being due to the extensive character 



DYSENTERY. 203 

of the local lesion, profound exhaustion of the system, or to 
complications. 

The Pseudo-membranous (or diphtheritic) form. — This type 
affects the colon, but exceptionally extends into the lower 
ileum. If the case is mild, the tops of the folds of the colon are 
covered by thin, yellowish-gray membrane; if severe, the walls 
of the gut are thickened and stiffened by the infiltration, the 
mucous membrane itself appearing as a tough yellowish-gray 
substance, composed of fibrin, pus and blood, and wanting in 
glandular elements. Sloughing occurs, involving the submu- 
cous and muscular layers. (The Army Medical Museum at 
Washington, D. C, has among other specimens a tubular cast 
fourteen inches long.) The separation of the slough exposes 
irregularly shaped ulcers as above described, which may even- 
tually perforate. 

This form may appear as a primary or as a secondary affec- 
tion. If the latter, it follows exhausting diseases (Blight's 
disease, cardiac affections) or certain acute diseases, more 
often pneumonia. 

Symptoms.— If primary, the onset is usually sudden and 
severe, with high fever, prostration, great pain, abdominal 
distension and tenderness, frequent stools, and even delirium, 
clinically resembling typhoid fever. The stools may contain 
mucus and blood, and at first commonly do, but the symptoms 
lack the clear-cut character of the follicular form, and tenes- 
mus is often absent. In the secondary form the bowel symp- 
toms are so negative that the intestinal lesion may easily be 
overlooked, a few copious, liquid, exhausting stools daily, not 
always containing mucus or blood, frequently constituting the 
sum total of symptoms presented. 

The primary form is rapidly fatal; if sloughing occurs 
promptly, recovery may take place, but with a strong tendency 
to assume the chronic form. Death in either form is preceded 
by profound prostration of the vital forces, low, muttering 
delirium, and coma; consciousness may be retained to the end. 

The Chronic form is marked by "atrophy of the glandular 
structure and hypertrophy of the wall of the bowel" (Whit- 
taker). Ulceration in various stages of development or heal- 
ing is frequently, though not always, present. The mucous 
membrane generally is rough, irregular and pigmented, steel- 



204 SPECIFIC INFECTIOUS DISEASES. 

gray or black; the presence of cicatrices gives to it a puckered 
appearance. The submucous structure and the muscular coat 
are hypertrophied, thus reducing the calibre of the intestine. 
Strictures occur rarely. C\'stic degeneration of the glandular 
elements may be present. 

Symptoms. — Chronic dysentery commonly follows an acute 
attack; the amoebic form may be subacute from the beginning. 

The chief difference, symptomatically, from the acute form 
lies in the absence of tormina and tenesmus and of blood and 
shreds in the stools. Mucus, in varying amounts, is frequently 
seen in the stools, especially when a stubborn constipation al- 
ternates with diarrhoea. 

Usually there is a thin, frothy diarrhoea, the stools contain- 
ing particles of food, more or less freely tinged with bile, their 
number varying from four to twelve, or more, in twenty-four 
hours. The appetite is fitful, digestion deranged, intestinal 
flatulence pronounced, and there is tenderness along the course 
of the colon. The tongue is usually red, beefy; later, dry and 
cracked. Anaemia, great weakness and extreme emaciation are 
common features. Acute exacerbations may occur; if so, the 
symptoms will resemble those of the acute form; or, owing to 
the general lack of tone, intercurrent disease, such as pneumo- 
nia or tuberculosis, may at any time seriously complicate the 
case. 

Complications and Sequelae of Dysentery.— Complications 
are infrequent. Those most liable to occur are: Malaria and 
typhoid fever; neither exert any marked influence upon the 
course of the dysentery, nor are they frequent in private prac- 
tice. Rheumatism (arthritis of the knee and other joints) may 
set in during the second week of dysentery or during convales- 
cence, usually continuing from four to six weeks. Pleurisy, 
pericarditis and endocarditis are seen in severe and protracted 
cases. Pyaemia is occasionally observed, and anaemic oedema 
has been noted where the anaemic state was very pronounced. 
Local peritonitis may occur from extension, and diffuse peri- 
tonitis from perforation (perityphlitis, periproctitis). Gan- 
grene of the intestine is sometimes an early complication; it is 
recognized b\>- the symptoms of collapse. Abscess of the liver 
has been seen in this country, and is very common in the 
tropics. Paraplegia, from neuritis, follows occasionally; 



DYSENTERY. 205 

corneal ulceration is even more rare. Intussusception and 
prolapse may result from excessive straining, especially in chil- 
dren. 

Perfect recovery from the chronic form is rare; in the great 
majority of such cases digestion remains permanently im- 
paired and there is left a persistent irritability of the bowel 
which becomes the source of much discomfort. 

Diagnosis. — Generally the diagnosis of dysentery is easily 
made, the presence of tormina, tenesmus, characteristic stools 
and rapid exhaustion of the patient establishing the nature of 
the case. This applies especially to the follicular form, save in 
isolated sporadic cases, in which prompt recognition of the dis- 
ease may be attended with difficulty. The amoebic form is 
recognized chiefly by the chronicity and irregularity of its 
course and by the presence of the amoebia dysenteric 

Diarrhoea at times bears some resemblance to dysentery, but 
has no marked persistent tenesmus and lacks the characteristic 
stools; it usually runs a shorter course and yields more readily 
to treatment. Choleraic conditions are distinguished by 
the suddenness of their onset, the profuse character of the 
vomiting and stools, and the cramps and tendency to collapse. 

Cancer or syphilis of the rectum may have considerable 
tenesmus, and the stools may be dysenteric in character; 
but the course of the disease, the absence of other symp- 
toms peculiar to dysentery and, above all, careful exam- 
ination of the rectum will reveal the nature of the affec- 
tion. Intussusception, in children, presents many symptoms 
which might mislead, particularly early in the case; among 
these are: vomiting, mucous and bloody stools, with tenes- 
mus, restlessness and prostration. Later, however, the in- 
vaginated mass can be recognized, especially in the right iliac 
and hypochondriac region; the pain and vomiting also are 
more persistent and severe. Typhoid fever resembles certain 
cases of dysentery, especially of the diphtheritic form; but the 
marked character of the nervous symptoms of the former is 
absent in the latter; typhoid fever has a characteristic temper- 
ature curve, the fever of dysentery is irregular and intermit- 
tent; the stools of typhoid fever resemble pea-soup, those of 
dysentery are characteristic as described; typhoid fever has 
epistaxis, enlarged spleen, and certain complications (bron. 
chitis) which are not seen in dysentery. 



206 SPECIFIC INFECTIOUS DISEASES. 

Duration and Prognosis. — The duration of the average case 
of the catarrhal or follicular type is from eight to ten days 
after the establishment of the dysenteric symptoms. The epi- 
demic form may continue for weeks or months; chronic cases, 
for months and years. 

Death results from asthenia or from complications; excep- 
tionally a fatal termination is reached within a few hours. 

The prognosis in the lighter forms is good; children and old 
people furnish a somewhat higher rate of mortality than those 
in early adult life. Epidemics vary greatly in severity and fa- 
tality; in the less fatal epidemics an average rate of mortality 
of 5 to 10 per cent, obtains; but the loss has in many instances 
reached from 60 to 80 per cent. The great fatality of some 
epidemics is undoubtedly due to specially unfavorable condi- 
tions, as bad food, confinement in bad quarters, great mental 
depression, etc.; it is thus that the frightful rate of mortality 
among prisoners of war and soldiers in badly arranged and 
badly situated camps, with their necessary exposure, unwhole- 
some food and depressing influences, is largely explained. 

One attack affords considerable immunity from others. 

Treatment. — Prophylaxis consists of attention to wise living 
and obedience to sanitary laws. Tropical countries require 
special precautions which need not be considered here. The 
wants of large bodies of men, congregated in camps or prison, 
must be studied and supplied by those in authority. 

The individual case requires careful attention. The patient 
should be isolated in a room having an abundance of fresh air. 
Perfect rest in a horizontal position, from first to last, must be 
strictly enforced. In severe cases an attempt to assume the 
erect position is often followed by nausea and fainting, and 
must be prevented; in fact, the use of a bed-pan or of clothes 
in the bed, as receivers of the stools (the latter to be burnt as 
soon as soiled) is often imperative. The patient, for obvious 
reasons, should be urged to resist as long as possible the desire 
to empty the bowel. Cleanliness about the person of the sick 
must be scrupulous^ maintained. Clothes used must be dry, 
warm, promptly changed whenever soiled, then burnt. It is 
well to bathe the parts after the bowels have moved, using soft 
clothes and pure, n on -irritating soap. Vaseline, slightly car- 
bolized, is serviceable when the parts are chafed. Mild disin- 



DYSENTERY. 207 

fectants and deodorizers may be used about the person of the 
sick and in the room, but cannot take the place of fresh air 
and cleanliness. The stools must be removed at once; if not 
burnt, they must be buried deeply and at a safe distance from 
the wells and house. Drink may be given with reasonable free- 
dom, as the patient desires and tolerates it. The water should 
be pure, boiled, then cooled, and given in small amounts and at 
frequent intervals. If not kindly borne, crushed ice, in moder- 
ate amounts, may be substituted. Carbonized water and acid- 
ulated drinks (lemonade) should be used -with caution, but in 
many cases are grateful and harmless. — Diet. Milk constitutes 
the most useful article of diet; in the majority of cases it acts 
best when boiled. If taken freely, watch must be kept upon the 
evacuations, the appearance of curdy or oily matter in the 
stools indicating the necessity of at least temporarily discon- 
tinuing its use. Whey, meat-broths, oysters, egg-albumen or 
scraped raw beef may be added or substituted. It is well to 
be somewhat influenced in the selection of the diet by the 
wishes or craving of the patient and by his habits of life. Of 
course, every departure from a line which experience has shown 
to be expedient and safe entails the necessity of increased 
watchfulness; yet, the extreme exhaustion common in dysen- 
tery warrants a constant effort on part of the physician to 
supply all the nourishment which can be properly assimilated. 
Stimulants are often demanded and kindly borne, especially in 
the latter part of the disease; milk-punch, with brandy or 
whisky, or wine, are usually relished, bracing and without ill 
effects. 

The patient beginning to show signs of improvement, there 
is an increased desire for food which justifies, on one hand, a 
little more freedom in the choice of food— as the addition of 
egg, rice, fowl, etc., — but, on the other, it necessitates the ex- 
ercise of especial watchfulness to avoid overfeeding or commit- 
ting serious errors. Ripe fruit and vegetables may be added to 
the dietary as the patient has fully entered upon convalescence. 
In chronic dysentery, extreme care in diet is absolutely neces- 
sary, the slightest mistake often giving rise to violent aggrava- 
tions or relapse. 

The distressing tormina and even the tenesmus may be greatly 
relieved by the use of small, thin injections of starch, to which 
from thirty to sixty drops of laudanum have been added. 



208 SPECIFIC INFECTIOUS DISEASES. 

The chief reliance of the dominant school at present is copi- 
ous irrigation of the bowel with water — cool, tepid, or at a 
temperature of 100°— to which silver nitrate (from 10 to 30 
grs. to the pint), alum (60 grs. to the pint), acetate of lead, or 
some other astringent, has been added. "It changes a huge in- 
ternal into an external abscess, and enables us to cleanse the 
bowel of its putrid contents" (Hare). 

Therapeutics. — The remedies most frequently indicated are: 
Mercury, Arsenicum, Belladonna, Colocynthis, Ipecacu- 
anha, Argentum nitricum, Lachesis. Of these, Mercury is 
by all means the most valuable. 

Mercury. The abdominal pain is severe, cutting, griping, 
constant; there is incessant and largely ineffectual straining, 
the patient having not a moment's rest from the pain in the 
bowels and the desire to go to stool; tenesmus often is agon- 
izing. The pains are severe before stool, and continue to in- 
crease until an effort at stool is made; this effort aggravates 
the suffering, but the straining cannot be controlled; expulsion 
of a small stool and cessation of straining brings no relief, 
rather a continuance of the aggravation, but after a little time 
a brief period of comparative rest follows. The stools at first 
are slimy, green, bloody (Merc. sol. Hahnem.), later they 
grow more frequent, become very scanty, and consist chiefly of 
bloody mucus and membranous shreds. There is urinary reten- 
tion or suppression. In the early stage, when the inflamma- 
tory symptoms are intense, the exhibition of Mercurius 
coRROsrvus in the 3d dec. trit. is often followed by immediate 
improvement and early recovery; it has also done good work 
in advanced cases, with symptoms of gangrene. — Belladonna 
is a useful remedy, particularly in children, when the stools are 
greenish, slimy, bloody, accompanied with much bearing-down 
and tenesmus, followed by smarting and burning in the rectum 
and anus. The abdomen is hard, swollen, sensitive to pressure; 
intense colicky, pinching pains in the abdomen cause the pa- 
tient to scream out; there is sense of fulness in the rectum and 
anus, with swelling and bulging out of the anal mucous mem- 
brane. Urine profuse, more often suppressed. Great restless- 
ness and nervous excitement. — Arsenicum, in addition to its 
characteristic restlessness, thirst, and exhaustion, has: watery, 
yellowish, foul stools; chocolate-colored stools; bloody stools, 



DYSENTERY. 209 

containing pus, shreds, bits of faecal matter, fluid or coagulated 
blood, dark, almost black. The stools are preceded by cutting 
pain and restlessness; they are followed by burning pain in the 
rectum and great exhaustion. The face is sunken; the skin dry 
and hot, or there is clammy coldness of the entire surface. The 
pulse is weak and rapid. It is of great service in severe cases 
when there is extensive breaking-down of tissue. — Colocyn- 
this is an excellent remedy when the patient suffers severely 
from griping, colicky pains extending from the navel down- 
ward, and relieved by pressure and "bending double." The 
stools are frequent, contain mucus and blood, are accompanied 
with considerable straining and tenesmus, and are followed by a 
sense of great relief which continues for several minutes. It lacks 
the intensity of inflammatory action which belongs to Mer- 
cury and the profound constitutional depression of Arsenic. 
—Ipecacuanha, like Mercury, has been highly recommended by 
clinicians of the dominant school, especially in the dysentery 
of the tropics. Given in minute doses it is useful in children 
oftener than in adults, particularly when the disease is brought 
on by eating unripe fruit. The stools are dark-green, full of 
mucus, frothy, accompanied with violent colic and tenesmus. 
There is much gastric derangement, moist, yellowish-white 
tongue, loathing of food, and nausea and vomiting. — Argen- 
tum nitricum is one of the best remedies in advanced cases 
when the evacuations are shreddy, ropy, green, with slight ad- 
mixture of blood, burning soreness and constriction in the ab- 
domen, and severe cramp-like, constrictive pain in the rectum. 
— Lachesis has dark, slimy, chocolate-colored stools, of foul, 
cadaverous odor, which look like charred straw; they are 
passed with much painful straining and burning at the anus. 
Great prostration of the vital forces; typhoid condition.— 
Aconite may prove serviceable when the first symptoms are 
characteristic fever, restlessness, thirst, and general arterial 
tension. — Rhus toxicodendron is useful, especially in children, 
when the discharges are of the consistency of jelly or like the 
washings of meat; there is tearing pain down the thigh, with 
uneasiness and relief from changing position or moving about 
in bed. Podophyllum, Aloe, Apis (in chronic cases, with an- 
noying urging and frequent discharge of gelatinous mucus, 
without much tenesmus), Baptisia (remarkable prostration, 
14 



210 SPECIFIC INFECTIOUS DISEASES. 

quite out of proportion to the severity of the case, pain in the 
limbs, fever with much weakness, brown, dry tongue), Can- 

THARIDES, FERRUM PHOSPHORICUM, NUX VOM., ACID. NITRICUM, 

Kreasotum, Bryonia and China should also be consulted. 



TUBERCULOSIS. 

An infectious disease due to the presence of the bacillus tuber- 
culosis (b. Kochii), occurring in firm nodular bodies called 
tubercles or in diffuse infiltration of tissue, resulting in casea- 
tion or in sclerosis, with a tendency to ulceration, at times cal- 
cification. The disease may attack almost any organ or struct- 
ure of the body; in adults it most frequently affects the re- 
spiratory organs, and is then known as pulmonary tubercu- 
losis, phthisis pulmonalis, pulmonary phthisis, consumption. 

-/Etiology. — Tuberculosis is widely distributed. It spares no 
race or age, and is said to have a larger death-rate — about one- 
seventh of the total mortality — than any other disease. Ne- 
groes are very susceptible to tuberculous processes; among the 
American Indians, even though living in salubrious climates, 
the ravages of consumption are so extensive as to threaten the 
extinction of the race from this cause alone. The U. S. census 
of 1880 shows a ratio of 166 among the whites, 186 among 
the negroes, 286 among the Indians. 

Geographically, the distribution of the disease is general; it is 
rare toward the poles and in high altitudes; it thrives best in 
large centers of population, with coincident insanitary condi- 
tions. 

The disease also affects animals, among them chiefly cattle 
and fowls; hogs and sheep suffer from it less often, and horses 
are comparatively free from it. Pets about the house, as cats 
and dogs, readily become affected from association with tuber- 
culous people, and in turn may convey the disease to others. 
Wild animals in a state of nature seem to be free from tuber- 
culous disease; in captivit} r they often die of consumption. 

The specific cause of the disease is the bacillus tuberculosis 
(b. Kochii). It occurs in slender rods, of the length of one- 
third to almost one-half of the diameter of a red blood corpus- 



TUBERCULOSIS. 211 

cle; slightly curved or straight, and "uniform throughout its 
length, except where it is apparently broken by intervening 
highly refracting spherical spaces, four to eight in number, 
which are regarded as spores," and which by others are con- 
sidered the result of uneven staining. It is invested by a very 
dense membrane, and is capable of resisting for a considerable 
length of time heat and other destructive agents. It lives, but 
does not multiply, outside of the human body, thrives in the 
human body and in that of several warm-blooded animals, and 
grows on blood-serum, glycerin-agar and potato, kept at 
blood heat. The growth is slow, appearing at the end of the 
second week, forming "thin, grayish- white, dry, scale-like 
masses on the surface of the culture medium." Staining is 
necessary for the study of the bacillus. Ehrlich advises the fol- 
lowing method: "Add 5 cc. of pure aniline oil to 500 cc. of dis- 
tilled water; shake, and filter to remove the excess of oil. To 
this aniline water add 11 cc. of a saturated solution of fuchsin 
and 10 cc. of alcohol. Sputum may be readily examined by 
placing a minute quantity of it between two cover glasses and 
spreading it into a thin layer by pressure. The glasses are 
now to be separated by a sliding movement and dried. Then 
place the cover glasses in the staining material for twenty -four 
hours or, if more rapid results are desired, into a quantity of 
the stain which has been raised to the boiling point, the hot 
fluid coloring satisfactorily in a few minutes. The stain is 
next removed from all but the tubercle bacillus by washing for 
a few seconds in a mixture of nitric acid and distilled "water 
(1-4), the acid is to be immediately removed by washing once 
or twice in distilled water. If it is desired to examine the 
specimens in Canada balsam, the cover glass must be first 
placed in 95 per cent, alcohol for a few minutes; but if glycerin 
is used, this step is not necessary." (Goodno.) 

It is stated that sputum is nearly a pure culture of the bacil- 
lus of Koch, and that, even when diluted 1:400,000 times, it is 
still capable of propagating tuberculosis in animals especially 
susceptible to the disease, as guinea pigs or rabbits. The num- 
ber of the micro-organisms thrown off in the sputum is enor- 
mous; thus Nuttall, quoted by Osier, from a patient moder- 
ately advanced in tuberculosis estimated that in sixteen 
counts, made during a period of about six weeks, there were 



212 SPECIFIC INFECTIOUS DISEASES. 

thrown off from one and a-half to four and one-third billions of 
bacilli. 

The bacilli are present in all tubercular lesions, especially 
during a period of acute development; the more chronic the 
process, the smaller the number of bacilli present, particularly 
when seated in the joints or lymph glands. In some old lesions 
culture or inoculation are required to demonstrate their pres- 
ence. 

Infection may be brought about in various ways. Most fre- 
quently the disease is transmitted through the inhaled air, par- 
ticles of dust floating in it, affording abundant lodgment to the 
many bacilli set free by the drying-up of expectorated sputum. 
The fact alone that in the large majority of cases the respira- 
tory organs are primarily the seat of the tuberculous affection 
strongly argues in favor of this view; it is further emphasized 
by the prevalence of tuberculosis among those who live a 
strictly in-door life, as in cloisters, prisons, etc., or who, like 
professional nurses, are in close contact with consumptives. 
Statistics have been offered to disprove this assertion, as from 
the Brompton Consumption Hospital, but they only demon- 
strate the efficacy of such protection against the infectious 
agent as is afforded b}' good sanitation and special care. Ex- 
periments made b} r Cornet, and others, have positively proved 
the danger arising from the infectious character of the dust on 
walls of the rooms occupied by tuberculous patients, even for a 
period of six weeks after death, and series of fatal cases have 
been traced to infected houses or rooms and berths on steamers 
and sleepers. The commonly accepted belief that the expired air 
of tuberculous patients may transmit the infection does not 
rest upon facts. 

To what extent hereditary transmission exists has not yet 
been determined. That in rare instances tuberculosis occurs 
congenitally in man is undoubtedly true; but the very fact that 
such cases are almost isolated possesses great significance. 
Authorities incline to the belief that in the majority of cases in 
which the possibility of hereditary transmission may be con- 
sidered there is a "prolonged latency" of the A T irus, ready, 
upon slight provocation, to become active. The case of Birch- 
Hirschfeldt, who found that portions of the viscera of a foetus 
born of a phthisical mother, though containing no tubercles, 



TUBERCULOSIS. 213 

were infective to guinea pigs, is very suggestive. Baumgarten 
argues that the virus is transmitted, but that the disease may 
not show itself until a considerable period of time has elapsed, 
and in proof of this he refers to the frequency with which tuber- 
culosis is seen in sucklings and to the occurrence of tuberculosis 
in regions of the body practically beyond the reach of acci- 
dental infection, as in the bones and joints. 

That nearly every tubercular disease has a history of seem- 
ingly inherited tubercular tendency is a well-known fact; it 
should not be forgotten that the frequency and the extensive 
distribution of tuberculosis alone largely explains this, not to 
consider the important item of constant exposure to accidental 
infection on part of the possibly non-tuberculous children of 
'parents dying from tuberculosis. Yet, direct transmission of 
the disease from parent to child, especially from the mother, 
seems an established fact. 

Inoculation by tuberculous matter was first demonstrated by 
Yillemin (1865). It is now accepted as fully proved that 
tuberculous matter is the only agent which by inoculation can 
produce tuberculosis. Persons who are brought in frequent 
contact "with dead bodies or animal products, such as demon- 
strators of morbid anatomy, dealers in hides, etc., suffer from 
this form of tuberculosis. It usually remains local, but may 
give rise to constitutional infection. The "Leichen tubercle" 
or "post-mortem wart" is a case in point. Other modes of 
inoculation arise from the use of articles which have been about 
the person of a consumptive, either ornaments (as, for instance, 
ear-rings) or wearing apparel; injuries, such as a cut inflicted 
with a broken dish used as a container of tuberculous sputum; 
lips of a tuberculous person coming in contact with an abraded 
surface, as during the Jewish ceremony of circumcision or, as 
occurred in a case under my observation, of a tuberculous per- 
son sucking a wound inflicted upon the body of a friend by a 
snake-bite. B. F. Gamber relates the case of a young infant, 
evidently in perfect health, accidentally getting hold of and suck- 
ing a handkerchief saturated by tuberculous sputum, and dying 
within a few weeks of acute tuberculosis. 

Infection by the milk of tuberculous cows is no longer a 
matter of doubt; experiments upon a large scale are conclusive 
upon this point. Tubercular mammitis in the cow need not be 



214 SPECIFIC INFECTIOUS DISEASES. 

present, and yet bacilli may occur abundantly in the milk. Pigs 
fed upon such milk soon become tuberculous. Osier points out 
that the remarkable frequency of intestinal and mesenteric 
tuberculosis in children probably finds its explanation in this 
mode of infection. Infection through the use of tuberculous 
meat is also possible, but is greatly lessened by the thorough 
cooking to which meat usually is subjected. 

Among the predisposing causes most writers recognize the 
existence of a constitutional bias toward tuberculosis which 
defies description. The old-time pictures of the ill-shaped, 
narrow, flat chest as indicative of the so-called consumptive 
habit have ceased to be satisfactory since the profession have 
learned that almost as often those of expansive and well- 
rounded chest fall victims to this disease, and that a sunken 
chest-wall more frequently is a proof of actually existing tuber- 
culosis." 

Any condition which lessens the integrity of any portion of 
the respiratory apparatus or its powers of resistance may be 
considered a predisposing cause. It is thus that catarrhal in- 
flammation, especially bronchial catarrh, assumes an import- 
ance which it could not have save in its relation to tuberculosis, 
a relation so obviously close that even the masses recognize the 
danger of "letting a cold run." It is in the same light that a 
narrow, flat chest is to be looked upon with suspicion, as indi- 
cating, if not a tuberculous condition, at least the probability 
of an inherent weakness or lack of development of the pulmon- 
ary tissue. In the same manner traumatism, accidental or 
from an operation, or any disease which may reduce the vitality 
of the pulmonary tissue, such as pneumonia or bronchitis, may 
become a predisposing cause. Operative treatment of tuber- 
culous lesions, as resection of a tuberculous joint, may result 
in general tuberculosis. The constant inhala tion of air charged 
with particles of dust or other irritating, finely divided sub- 
stances has the same effect, setting up local irritation and cir- 
cumscribed inflammatory action, eventually resulting in a 
respirator}- apparatus so weakened that the infectious matter 
need only be introduced to thrive abundantly. Hence the start- 
ling mortality from tuberculosis among laborers whose occu- 
pation involves such exposure. It is stated upon good authority 
that of glass-workers, 80 per cent.; of needle-sharpeners, 70 per 



TUBERCULOSIS. 215 

cent.; file-cutters, 62 percent.; and stone-cutters, 60 per cent., 
die of pulmonary consumption. Specific fevers, by lowering 
vitality and impairing nutrition, and fevers associated with 
bronchial catarrh, as measles, are, for a similar reason, often 
followed by tuberculosis. 

Soil and locality bear no direct relation to tuberculosis, save 
as dampness predisposes to catarrhal affections, and they, in 
turn, predispose to tuberculosis. No age is exempt, but in 
childhood the lymphatic glands, bones, and meninges are most 
commonly involved. In young children the mesenteric and 
bronchial glands are particularly prone to tuberculous disease, 
and the meninges are especially liable to the affection. In 
adults, pulmonary tuberculosis is not only the commonest form 
of the disease, but it is rare to find a case of general tuberculosis 
in an adult without involvement of the lung. 

"The tuberculous process." — The nodular tubercle at first 
presents no truly characteristic feature. The distinctive 
changes due to the presence of the bacilli and occurring later 
are summarized by Osier as consisting of " a proliferation of the 
fixed elements, with the production of epithelioid and giant 
cells; and, secondly, an inflammatory reaction, associated with 
exudation of leucocytes." The tubercle, in due time, under- 
goes caseation or sclerosis. 

Coagulation necrosis begins in the center of the growth, 
resulting in the formation, of a homogeneous, structureless 
mass, no longer susceptible to staining, extending from the 
center toward the circumference, and eventually converting the 
tubercle into a yellowish gray body, void of blood-vessels, 
containing bacilli. This constitutes the cheesy degeneration of 
the tubercle, which finally terminates in softening, fibroid 
limitation (encapsulation), or calcification. 

Nature attempts to preserve the integrity of adjoining struct- 
ures by restricting this process by means of hyaline transforma- 
tion, with a marked increase in the fibroid elements, carried on 
with especial activity in the outer zone of the involved tissues, 
practically encapsulating the area of broken-down tissue. 
Thus there is going on at the same time in each tubercle a 
double process, one destructive and dangerous, the other con- 
servative and life-saving; the issue of the case depends upon the 
preponderance of one of these. If capable of effectively restrict- 



216 SPECIFIC INFECTIOUS DISEASES. 

ing, by sclerosis or encapsulation, the growth of the bacilli- 
laden tubercle, life and usefulness may be prolonged. 

The tuberculous lesions may involve the various tissues of 
the body, but show a preference for the connective tissues. 
Should the bacilli per-chance enter the blood-vessels or lymph 
channels, their distribution becomes general throughout the 
body. 

The so-called diffuse, infiltrated tubercle, commonly found in 
the lung, is to all intents and purposes a fusion of many small, 
at times microscopic, foci of infection, with a tendency to rapid 
caseation, involving areas of varying extent, usually occurring 
in groups of lobules, sometimes involving an entire lung. The 
term "gray infiltration" of Lamnec is used to describe the 
gray, gelatinous appearance of the affected parts in the early 
stage. The term "cheesy pneumonia" covers a more extensive 
infiltration, with large areas of caseation. This infiltration 
may be so diffuse, without any special foci, as to practically 
constitute a true tubercular pneumonia. 

Secondary inflammatory processes are a natural sequence. 
If of moderate intensity, there is that formation of cicatricial 
connective tissue which ' ' constitutes the conservative element 
in the disease." If severe, exudation of leucoc3^tes and serum 
results, and the tuberculous growth may be surrounded by an 
area presenting all the histological features of a true pneumonia. 

The suppuration which so commonly occurs in connection 
with tuberculous processes is held to be due to mixed infection. 
It is, however, admitted that the tubercle bacilli, and especially 
their products, are in themselves capable of exciting suppura- 
tion. 

ACUTE MILIARY TUBERCULOSIS. 

An eruption of miliary tubercles affecting the different struct- 
ures and organs of the body, preferably the pleura, perito- 
neum, lungs, lymphatic glands, liver, spleen, kidneys, and cere- 
bral meninges; at times they are equally distributed through- 
out the body; again, they are massed in one organ and scarce 
in the others. 

Acute miliary tuberculosis may arise from any of the causes 
to which is attributed the appearance of the disease in any 
other form. There is* however, a growing tendency to the be- 



TUBERCULOSIS. 217 

lief that in very many cases, perhaps in the majority of cases, 
this form of tuberculosis is due to auto-infection, starting from 
some focus of tubercular disease which has existed without 
being recognized, as in the lungs, lymph-glands, or elsewhere. 
The rupture and subsequent discharge of a tubercular mass into 
a vein or into some lymph-channel is sure to scatter the bacilli 
broadcast throughout the system and to bring on general in- 
fection. 

Three types are distinguished: the typhoid form, the pulmo- 
nary form, the meningeal form. 

THE TYPHOID FORM. 

This form consists of a general infection, with constitutional 
symptoms which so closely resemble those of typhoid fever 
that, often, a differential diagnosis becomes difficult. In excep- 
tional cases the onset is abrupt; usually, indisposition, loss of 
appetite, slight feverishness, and sense of weakness are noted. 
Shortly the fever becomes pronounced, with, commonly, even- 
ing rise in temperature and remissions in the morning; the 
pulse-beat is weak, rarely dicrotic, corresponding in rapidity to 
the height of the fever; the tongue is dry and brown; there is 
flushing of the cheeks; delirium; more or less pronounced bron- 
chitis, with increased frequency of respiration; considerable 
nervous involvement; constipation, at times diarrhoea, rarely 
with admixture of blood; enlargement of the spleen and albu- 
minous urine are generally present; occasionally there is seen 
jaundice, herpetic eruptions, and petechia?, the latter especially 
about the wrist. 

The fever is irregular. The temperature in the evening may 
rise to 103° or 104° P., and even as high as 106°; in the morn- 
ing a marked remission is observed, sometimes even a fall to 
below normal; at times this order is reversed and the highest 
temperature reached in the morning. Afebrile cases have also 
been observed. Exceptionally, severe night-sweats and suda- 
mina are persistent. 

The nervous symptoms may be well-pronounced, consisting 
of delirium, which is rarely active, with a tendency to mental 
dullness drifting into a fatal coma. 

Symptoms of bronchitis are almost always present, very 
much as they are observed in typhoid fever. Occasionally the 



218 SPECIFIC INFECTIOUS DISEASES. 

pulmonary involvement is extensive, and then impresses its 
symptomatology upon the form of the disease, increasing the 
respiratory movements and pulse. 

Diagnosis. — As stated, the differentiation from typhoid fever 
is often exceedingly difficult. The diagnosis of acute tubercu- 
losis rests upon the greater frequency of respiratory move- 
ments; the comparative infrequency of cough; pronounced 
diarrhoea and jaundice; the more moderate enlargement of 
the spleen, which occurs later than it does in typhoid fever and 
is more pronounced in children than it is in adults; the absence 
of roseola; the irregularity of the fever; the absence of 
the characteristic temperature curve of typhoid fever; and the 
presence of leucocytosis. Bacteriological tests may be re- 
quired to make the diagnosis positive. 

The duration of the disease is from a fortnight to six weeks, 
or longer. 

The prognosis is unfavorable. 

THE PULMONARY FORM. 

Two classes chiefly furnish the victims of this type: persons 
who have been chronic sufferers from some pulmonary lesion, 
not necessarily tuberculous, and children who have just passed 
through an attack of measles, whooping-cough, or some severe 
infectious disease. 

The symptoms are almost always those of a severe bronchi- 
tis, with hard cough, muco-purulent, sometimes rusty, expec- 
toration, occasionally bleeding, and dyspnoea which sets in 
early and attracts attention because it is quite out of propor- 
tion to the physical signs developed. Breathing is hurried, 
reaching in adults from fifty to sixty, and in children as many 
as eighty, or more, respirations per minute. Cyanosis is pro- 
nounced throughout the course of the disease. 

Examination of the chest at this time gives the physical signs 
of bronchitis, more or less diffused, or of a broncho-pneumonia. 
In some cases no characteristic signs can be detected. Per- 
cussion yields dullness at the bases, sometimes areas of hyper- 
resonance. Auscultation determines crepitation sounds, due to 
the presence of tubercles on the pleura, or rales of a sibilant or 
fine crepitant character. There may be high-pitched tubular 
breathing at the bases or toward the root of the lung. As the 



TUBERCULOSIS. 219 

disease progresses, large mucous rales are easily detected; the 
temperature rises to 102° or 103°; the pulse is rapid and feeble; 
derangement of the appetite, with vomiting and indigestion, 
persist; and enlargement of the spleen is present in cases that 
run a rapid course. 

Death usually occurs from general infection, exhaustion, 
heart failure or pulmonary oedema. 

The diagnosis presents no special difficulty. The history of 
the case alone usually furnishes the key to the nature of the 
disease. The early and marked dyspnoea, in connection with 
the pulmonary symptoms and the pronounced tendency to 
cyanosis, are almost characteristic. The presence of bacilli is, 
of course, of the highest diagnostic importance. 

The duration of the disease varies; death may occur within a 
few weeks or the case may linger for months. 

The prognosis is unfavorable. 

THE MENINGEAL FORM. 

This form will be discussed in a subsequent chapter (see 
Organic Diseases of the Brain; Affections of the Meninges). 

Treatment. — The prophylaxis and treatment of all tubercular 
affections is necessarily the same, save as it must be modified 
by the exigencies of each particular form. They will be dis- 
cussed in full under pulmonary tuberculosis, the form most fre- 
quently met in general practice. In the same chapter thera- 
peutics will be discussed. The typhoid form requires the same 
careful attention to feeding which is practiced in the treatment 
of typhoid fever. Small amounts of milk are to be administered 
at frequent intervals. Koumyss, peptonized milk, soups, beef- 
tea, broths, gruels, and other easily digested and nourishing 
substances maybe given in small amounts and at short periods. 
If tolerated, alcoholic stimulants may be used in moderation, 
especially iced champagne -when the stomach is irritable. Bits 
of broken ice may be allowed to quench the thirst; ice-cream, a 
grateful means of conveying nourishment and of relieving the 
heat and dryness of the feverish mouth and throat; sponging 
in hot or cold water; alcohol baths; inunctions with cod-liver 
oil or pure olive oil; various methods of artificial feeding — all 
these are to be employed as occasion for their use arises. 

Remedies must be prescribed symptomatically, and those 



220 SPECIFIC INFECTIOUS DISEASES. 

most likely to prove of service will be found in the chapter on 
typhoid fever; of these, Arsenicum is one of the most reliable. 
The pulmonary form requires the treatment and general 
management given in full under pulmonary consumption. 

TUBERCULOSIS OF THE LYMPHATIC GLANDS. 

(Scrofulosis or Struma.) 

It is generally conceded that the presence of Koch's bacillus 
constitutes "the essential element" of this disease. Several im- 
portant clinical features of the scrofulous affection, as its tend- 
ency to remain localized and its self-limitation, have not yet 
been satisfactorily reconciled to this etiological theory, save as 
the experiments of Arloing and Lingard tend to prove that the 
virus, here, is much less active than that which produces the 
true tubercular process. 

Donkin describes scrofulosis as "a largely hereditary tendency 
to congestion and inflammation of various parts and organs, 
which is especially marked in the lymphatic structures and 
glands. Imperfect nutrition and circulation underlie these 
morbid expressions, which are seen chiefly in children born and 
reared in bad hygienic conditions, with, frequently, a vicious 
heredity as well. Parental syphilis and phthisis underlie 
struma in numerous cases, while bad food and the deprivation 
of pure air and light are probably guilt}- of many more. Ton- 
sillar enlargement, with recurring inflammation, is a common 
mark of this condition, mostly accompanied by a similar affec- 
tion of the glands of the neck. These glands may only swell 
and after a while subside, but frequently suppurate, and then 
nearly alwa3 r s become more or less caseous. In close connec- 
tion with this glandular affection we find disease of the bone, 
swelling of joints, and various affections of the skin and mucous 
membranes." To the predisposing causes enumerated by 
Donkin should be added that "increased vulnerability of 
tissue" ( Virchow) which results from chronic or often recurring 
catarrhal inflammation of the mucous membrane. 

The most characteristic features of tuberculous lymphadenitis 
are: Remarkable chronicity; tendency to remain localized, al- 
though, until thoroughly healed, a focus of tuberculous adenitis 
may at any time become the source of general tuberculous in- 



TUBERCULOSIS. 221 

fection; predisposition to slow, spontaneous healing; tendency 
to suppuration. 

Clinical Forms. — General tuberculous lymphadenitis is very 
rare. It consists of a general tuberculous involvement of all 
the lymph glands of the body without, or with little, tuber- 
culous involvement of other parts. It shows a preference for 
the mesenteric and retro-peritoneal glands, and often affects 
the bronchial and, sometimes, groups of external, glands. 
When occurring in an acute form it resembles Hodgkin's dis- 
ease. As stated, in an overwhelming majority of cases the 
disease is local; it then involves the cervical, the bronchial, or 
the mesenteric glands. 

a) The cervical form. — This is the form commonest seen in 
children, especially among the poor, badly housed and badly 
fed; it is frequent in foundling asylums and similar institutions, 
and shows a preference for the negro. Nasal and pharyngeal 
catarrh, enlarged tonsils, catarrhal affections of eye and ear 
(purulent otitis), and eruptions of the scalp or skin are likely to 
be associated with it. 

Slight enlargement of the maxillary glands ("kernels"), larger 
on one side, gradually increases until it becomes a firm, smooth, 
isolated tumor or hard, knotted mass, upon which the skin 
usually is freely movable. In other cases, with a higher degree 
of inflammatory action, the skin adheres. The tendency is to 
suppuration, which develops tardily; if allowed to burst, there 
is left a sinus which it may require an indefinite length of time 
to heal. 

The entire process is exceedingly tedious. Aneemia may be- 
come well pronounced when suppuration continues long, but 
even in serious uncomplicated cases the prognosis, as to life, is 
favorable. Some fever is present during the progress of the 
case, with general indisposition, loss of appetite and marked 
debility. If inflammatory action is active and the process more 
than usually intense, the fever is correspondingly high. 

Other glands may become involved. Thus, the supraclavicu- 
lar glands and those of the posterior cervical triangle may be 
affected. Or the cervical and axillary glands may become en- 
larged, forming a continuous chain, which extends beneath the 
clavicle and pectoral muscle. The bronchial glands, also, may 
be involved, greatly adding to the gravity of the case, for the 



222 SPECIFIC INFECTIOUS DISEASES. 

more extensive the involvement, the greater the danger result- 
ing from cachexia and of extensive, possibly general, infection. 
Thus, the enlargement of the supraclavicular and axillary 
glands on one side is very liable to result in tuberculous infec- 
tion of the pleura or of the pulmonary tissue. 

b) The bronchial form also is of frequent occurrence, a fact 
which is probably due to the readiness with which the medias- 
tinal glands about the bronchi catch the accidentally inhaled 
tubercle bacilli. The tumors may be large and suppurate. 
There is here especial danger of infection of the pericardium, of 
the lungs, and of the system generally. 

c) The mesenteric form, also called tabes mesenterica or ab- 
dominal scrofula, consists of enlargement and caseation, more 
rarely calcification and suppuration, of the mesenteric and 
retro-peritoneal glands. It may be primary or secondary. The 
former is associated with intestinal catarrh; the latter is an 
incidental feature of general tuberculosis of the intestine or, 
more particularly in adults, of pulmonary tuberculosis. 

Children oftener than adults suffer from this form. The 
symptoms are chiefly those of innutrition, progressive loss of 
flesh, strength and energy, fever of moderate intensity, anaemia, 
enlarged and tympanitic abdomen, diarrhoea of thin, offensive 
stools, and constantly increasing, pronounced debility. 

The great distension of the abdomen renders it very difficult, 
if not impossible, to detect the enlarged glands; should the 
peritoneum become involved, as it occasionally does, the ab- 
dominal wall is firm and comparatively unyielding, and the 
nodules ma}^ then be readily felt. 

Treatment. — The prophylaxis of scrofulosis consists of 
measures to modify and eradicate the inherited predisposition. 
Even during early infancy" careful attention should be paid to 
every expression of the scrofulous tendency. Soft woollen un- 
derwear of full length, adapted in weight and thickness to the 
season of the year, must be worn to prevent sudden chilling of 
the surface of the body and catarrh of the respiratory mucous 
membrane. Irritation of the skin, chafing, etc., is to be 
avoided by thorough attention to the toilet of the infant or 
child. Regular sponging in a warm room is commendable, but 
too frequent bathing, especially in a bathtub, or bathing in 
water of a low temperature, must be avoided, since it is liable 



TUBERCULOSIS. 223 

to exhaust vitality rather than stimulate. If old enough, sea- 
bathing is excellent; in small children, or when sea-bathing 
cannot be had, a salt-water ■ sponge-bath may be substituted. 
Change of climate, permanent or for a considerable period of 
time, is desirable; this implies an out-door life away from 
fashionable hotels and from places where the patient is con- 
stantly subjected to danger from tubercular infection. Diet is 
of importance. If an infant, it should be fed at the breast; if 
for some special reason suckling is out of question, a compro- 
mise in the -way of artificial feeding must be s made. Meigs 
offers the following excellent formula: One quart of good ordi- 
nary milk is placed in a high pitcher or other vessel, and al- 
lowed to stand in a cool place for three hours; then one pint is 
slowly poured off from this, care being taken that the vessel is 
not agitated, the object being to obtain the upper layer of the 
fluid, rich in fat, and leave the lower, comparatively poor, por- 
tion behind. When the child is to be fed, there are taken of this 
weak cream three tablespoonfuls, of lime-water two table- 
spoonfuls, and of sugar- water three tablespoonfuls, the sugar- 
water being made in the proportion of eighteen drachms of 
milk-sugar to a pint of water. The usual precaution as to ab- 
solute cleanliness in the apparatus used for feeding must be ob- 
served, and the lime-water may be diluted when its presence 
renders the milk distasteful to the child. As the little patient 
grows older, and takes food more freely and in greater variety, 
milk still heads the list; care should be had to procure it from a 
healthy cow; if obtained from the city-milkman, it may be well 
to sterilize it. Well-cooked cereals; bread at least twenty-four 
hours old, and in due time broths may be added to the dietary. 
Fat, in moderate amount, is highly advantageous; cream, 
olive oil and cod-liver oil should be used freely but -wisely, 
always taking pains to discontinue, at least temporarily, any- 
thing that is distasteful or distressing. By attention to these 
suggestions and by taking pains to have the growing child live 
a thoroughly normal life, the scrofulous tendency may be so 
completely modified that it ceases to be a source of danger in 
after-life. 

Therapeutics. — The remedies oftenest indicated in the early 
stage are Calcarea carbonic a and Baryta carbonic a. The 
indications for both are generally known. The former corres- 



224 SPECIFIC INFECTIOUS DISEASES. 

ponds closely to all the constitutional expressions of the scrofu- 
lous diathesis, and, perse veringly used, has done much valuable 
work; the latter, almost as profound in its action, has been of 
particular service when a stubborn tendency' to nasopharyn- 
geal catarrh existed in children of scrofulous tendency. 

When the glandular swelling has become persistent and 
prominent, Belladonna, Asa fcetida, Conium, and Iodine are 
to be consulted. — Belladonna acts best in children who are sub- 
ject to attacks of congestion in different parts of the bod}', en- 
ergetic, and of full, plethoric habit. The swelling is hard, more 
than usually sensitive to the touch, with a tendency to com- 
paratively rapid inflammation and suppuration. The charac- 
teristic redness, with red streaks radiating from the center out- 
ward, is sometimes noticed. — Asa fcetida is useful in "scrofu- 
lous, bloated, clumsy children, of phlegmatic temperament," 
when the glands are hot, hard, with throbbing, shooting pain. 
Gilchrist has found it of service when fistulous openings had 
formed, with stinging pains in the parts, changed in character 
by touch, and with dark-colored discharge of putrid, cadaver- 
ous odor. — Conium: the glands are of stony hardness, some- 
times painless, again with darting, stitching pain; shooting, 
drawing pain in the tonsils; scraping in the throat; constant 
hawking; sense of constriction in the throat, as from tightness 
of the shirtband. Sensitiveness and sticking pain in the region 
of the liver. Griping, sticking, knife -like pain throughout the 
abdomen, which is much distended. Watery diarrhoea. — Iodine: 
chronic catarrh, with swollen, painful nose and fetid discharge; 
aural catarrh, with deafness; children of dark complexion and 
ravenous appetite, who remain thin and scrawny in spite of eat- 
ing ravenously. Swelling hard and firm, and not very large. The 
external use of iodine should be avoided; under its employ- 
ment the swelling may possibly disappear, but not without 
great danger of causing pulmonary complications. 

Suppuration established, Hepar sulph., Silica, and aIer- 
curius are to be studied. Special indications for them ma} r 
here be omitted. Silica, more fully than Hepar, covers the 
ill effects liable to arise from prolonged and extensive suppura- 
tion. Both remedies must be given perseveringfy, and in doses 
not too crude, to yield their best effects. Mercury is closely 
related to Hepar sulph.; a "greasy" condition of the skin has 



TUBERCULOSIS. 225 

proved a good . indication. Graphites, Lycopodium, Mer- 
curius and Sulphur are useful when there are eczematous, or 
other, eruptions. 

Surgical procedures are often imperative. The swelling 
should not be allowed to burst, but a clean, full incision with 
the knife should be made to evacuate the pus. Poulticing 
should be done sparingly, if at all. Under favorable conditions, 
i. e. v^hen no attachments exist, the enlarged gland may be 
enucleated. 

PULMONARY TUBERCULOSIS. 

The bacilli invade the lungs by means of the circulation or ot 
the air inhaled. If the former, the air-cells and the adjacent 
meshes of connective tissue become the primary seat of the in- 
fection. The extent of this infection depends upon the number 
of bacilli introduced; one lobe, or one lung, or even both lungs, 
may be involved. The process terminates in sclerosis of the 
tubercle and fibroid transformation, or in caseation and soften- 
ing, which may involve extensive areas, or, if the parts are 
thickly studded with tubercles, in inflammatory involvement of 
the intervening tissues, constituting a true tubercular pneu- 
monia. If the bacilli are introduced by means of the air in- 
haled, i. e. inhalation tuberculosis, the bronchi and bronchioles 
become the primary seat of the infection; the tuberculous 
masses themselves are larger, and the area involved much more 
extensive. A tubercular broncho-pneumonia results, which 
may become limited by sclerosis of the tubercles or end in case- 
ation, ulceration, and the formation of cavities. 

Various classifications of pulmonary tuberculosis have been 
made, that into 1) acute pneumonic phthisis, 2) chronic ulcera- 
tive phthisis, and 3) fibroid phthisis, being the most practical. 
It must, however, be remembered that the essential aetiological 
element is the same in all forms; the same general and anatom- 
ical features prevail in them all; the characteristic symptoms 
of the disease are the same in all; and the termination and 
treatment of the individual case, no matter to what form it 
belongs, depend upon considerations which apply rather to the 
tubercular process as a whole than to any special form of its 
expression. 

Acute pneumonic phthisis — phthisis florida, galloping con- 
15 



226 SPECIFIC INFECTIOUS DISEASES. 

sumption — occurs in both children and adults, and may be 
divided into the pneumonic and broncho-pneumonic form. 

The pneumonic form, anatomically, presents the features of 
hepatization of the lung, affecting usually one lobe or an entire 
lung. The lung is heavy, airless; the pleura is commonly cov- 
ered with a thin exudation; the tissue is heavily charged with 
tubercles, and may present a grayish- white appearance; the 
affected areas may be circumscribed by injected, sometimes 
consolidated, lung tissue; cavities may form. In old cases 
caseous degeneration is abundant, and only narrow strips of 
elastic tissue may be met at the margins. 

The symptoms in the early stage are those of lobar pneu- 
monia, involving one lobe or an entire lung. The disease be- 
gins with a severe chill, followed by high fever; pain in the side; 
cough; frothy, then rust-colored expectoration; great, at times 
excessive, difficulty of breathing, with occasional suffocative 
attacks. The physical signs are those of tissue-consolidation, 
as dullness, increased fremitus, gradual disappearance of vesic- 
ular murmur, bronchial breathing. Instead of the usual crisis 
of pneumonia, between the eighth and tenth day, the symptoms 
continue without change, save as the general condition of the 
patient assumes a rather threatening aspect, indicated by in- 
creasing weakness, irregular fever, sweating, muco-purulent 
expectoration, and gradual^ developing evidence of softening, 
the expectoration now containing elastic tissue and tubercle 
bacilli. 

Death may take place early, in the second or third week, dur- 
ing the stage of consolidation, or the patient may linger for 
several months, the involved lung-tissue passing through soft- 
ening and cavity-formation. 

The diagnosis is beset with difficulties. During the early 
stage no physical, or other, signs can be detected which dis- 
tinguish this form of tuberculosis from non-tubercular lobar 
pneumonia. A suspicious family history or indisposition pre- 
ceding the attack may^ place the watchful medical attendant 
upon his guard, but a positive diagnosis is out of question until 
the appearance of the bacilli in the sputa. The character of the 
fever may throw some light upon the case, since remission of 
from one to two degrees in the temperature may occur in tub- 
erculous pneumonia, while the temperature of the non-tubercu- 
lous disease is more evenly sustained. 



TUBERCULOSIS. 227 

Acute tuberculous broncho-pneumonia is found among adults 
and children; in children it frequently follows infectious diseases, 
especially -whooping-cough and measles. A pronounced tend- 
ency to early caseous degeneration is peculiar. The bronchioles 
are filled with a caseous mass, while the air-cells of the lobule 
are in a state of catarrhal pneumonia, the affected area present- 
ing, first, a grayish-red, then a "cheesy," appearance. The 
areas of involvement differ in extent, and often are separated by 
fields of normal tissue; in other cases the entire lobe constitutes 
a mass of solid caseous substance. Again, areas of tuberculous 
affection are scattered throughout the lungs, preferably at the 
apices, the intervening tissue being comparatively healthy, but 
more commonly affording signs of. recent pneumonia or spleni- 
zation. The size of the tuberculous mass depends upon the size 
of the bronchus primarily infected; it presents the characteristic 
grayish- white, cheesy appearance, and may be as large as a 
cherry. 

The symptoms are: Chill or chills, high fever, rapid pulse, 
increased respiratory movements, rapid loss of flesh and 
strength. Physical examination shows the presence of areas 
of defective resonance, especially at the apices, harsh tubular 
breathing, rales scattered throughout the lungs, and elastic 
tissue and tubercle bacilli in the sputa. Exceptionally haemor- 
rhage is an early symptom. 

If the case is characterized by great intensity of action, a ty- 
phoid state may develop within three or four weeks, which 
usually terminates fatally within a short time. In other severe 
cases symptoms of tissue-softening, hectic and emaciation pre- 
vail for several weeks, and the patient appears in a most un- 
promising condition, -when suddenly he begins to improve and 
makes a partial recovery, the disease assuming a chronic form. 

In children the affection commonly sets in during convales- 
cence from whooping-cough or measles, with fever, cough and 
dyspnoea, which grow somewhat less after a week or two. 
The child, however, remains weak, loses appetite, flesh and 
strength, and physical examination shows areas of impaired 
resonance and rales in different parts of the chest. Hectic fever 
and sweating gradually develop, followed by pronounced 
symptoms of pulmonary tuberculosis. 



228 SPECIFIC INFECTIOUS DISEASES. 

CHRONIC ULCERATIVE PHTHISIS. 

The most frequent form of pulmonary tuberculosis, charac- 
terized by a tendency to softening and breaking down of tissue; 
in the course of the disease the affection changes from a purely 
tuberculous to a mixed infection. 

Morbid Anatomy. — The primary lesion is usually from an 
inch to an inch and a-half below the upper border of the lung, 
near the posterior surface; hence the physical signs are easiest 
detected with the ear at the scapula. Anteriorly, a spot just 
below the centre of the clavicle, and less often a spot correspond- 
ing on the "chestwall with the first and second interspaces 
below the outer third of the clavicle" mark the seat of the pri- 
mary lesion, the course of the disease extending downward, 
more often involving the right apex than the left. In some 
cases both apices are affected. Primary lesion may occur at 
the base, but not often. 

Chronic ulcerative phthisis is a complex affection, and in its 
long course presents a great variety of lesions, of which some 
have already been incidentally discussed. Miliary tubercles 
are frequently found in large numbers, especially in the lower 
lobes when the apices are involved; they may occur in firm 
sclerotic bodies, evenly and thickly scattered throughout, a 
true chronic miliary tuberculosis, or in various stages of trans- 
formation; again, only a few may be detected by the micro- 
scope. Broncho-pneumonia, of tuberculous origin, results from 
primary tuberculous infection of the smaller tubes and subse- 
quent involvement of their alveolar territory; rapidly pro- 
gressing caseation or ulceration in the bronchial wall results 
in breaking down of tissue and in the formation of a small 
cavity. In the more chronic form the tendency is to sclerosis, 
by which a tuberculous mass may become incased in a fibrinous 
capsule, the inclosed firm, caseous mass often holding calcare- 
ous bodies — lung stones — which not infrequently are thrown 
off with the expectoration during later ulcerative processes. 
Colonies of miliary- tubercles may be found outside of these 
capsulated masses. Their existence must necessarily be consid- 
ered a sign of continued danger. The inflammation of the 
alveoli within the territory of the infected tube constitutes a 
pneumonia which in some cases presents all the characteristics 



TUBERCULOSIS. 229 

of red hepatization, in others appears evenly infiltrated 
throughout. Resulting consolidation of tissue at times em- 
braces numerous foci of tuberculous infection, and thus may in- 
volve considerable areas of tissue. Sometimes the alveoli un- 
dergo fatty degeneration. Cavities or vomicae are almost 
always the result of dilatation of the walls of an infected 
bronchus by the accumulation of retained secretion, followed 
by necrosis and ulceration of the wall, extending by contiguity 
of tissue. A number of such cavities may communicate with 
each other, all emptying into a bronchus. It is possible that 
necrosis and softening may take place in the centre of a cheesy 
mass without primary involvement of the bronchial wall. In 
the chronic form of phthisis these vomicae have a limiting mem- 
brane whose inner surface produces pus. A slow but sure en- 
largement of the cavities takes place by necrosis and constant, 
tardy involvement of contiguous tissue. These cavities occupy 
the apex, vary in size, and may not only honeycomb the entire 
lung, but may in rare cases transform an entire lung into one 
large excavation. The contents of the cavity are usually puru- 
lent; remnants of tubes and blood-vessels are also seen. If 
the limiting membranes are very vascular, the expectoration 
shows free admixture of blood; if the wall has become gan- 
grenous, there will be great fetor of the expectoration. In 
other cases the cavities have no limiting membrane — fresh ulcer- 
ative cavities, — but their walls consist of soft cheesy structure, 
which may rupture and cause pneumothorax. The cavities are 
very large in acute tuberculo-pneumonic phthisis, often occupy- 
ing the greater portion of the upper lobe; they also occur con- 
stantly in chronic ulcerative phthisis in those portions of the 
lung which are newly involved. Nature attempts to render 
them harmless by surrounding them with a firm cicatricial 
tissue, and often succeeds in part; such cavities are said to be 
''quiescent." Complete healing takes place only in very excep- 
tional cases, and then only in cavities of small size. But even 
in large cavities a considerable protection against untoward 
effects, and a certain measure of limitation to rapid extension, 
is produced by an abundant development of connective tissue 
and resulting thickening. A peculiar feature in the formation 
of a cavity is the slow, gradual obliteration of the blood-vessels 
contained within it. Haemorrhage from these is a common 



230 SPECIFIC INFECTIOUS DISEASES. 

complication, caused by the erosion of the wall of vessels not 
yet wholly obliterated or by the rupture of an aneurismal 
tumor formed by the weakening of the wall of the vessel itself 
and hy the removal of supporting tissue. The pleura, is almost 
always involved . Pleuritis occurs commonly and in repeated at- 
tacks, and may be simple or tuberculous. If the latter, miliary 
tubercles or caseous masses are found in the thickened mem- 
brane. Adhesions are frequent, and differ in firmness and extent. 
Pleural effusions and pneumothorax are common. Catarrhal 
inflammation of the larger bronchi is a common feature of the 
disease, and really is an extension upward of the process which 
has involved the smaller tubes. The mucous membrane lining 
the larger bronchi becomes swollen and sometimes ulcerated; 
the tube- walls are weakened, and bronchiectasis may result. 
The nature of the process as it affects the bronchioles has been 
described. The bronchial glands are usually enlarged and 
oedematous. The}- commonly contain tubercle and caseous 
foci, and may undergo all the changes incident to the tubercu- 
lous process. They constitute, as pointed out, a chief source of 
constitutional infection. 

Of the involvement of more distant organs, tuberculous 
laryngitis, with ulceration of the vocal cords and destruction 
of the epiglottis, is one of the most important. Others are: 
tuberculosis of the brain, spleen, liver, kidneys, intestines, and 
pericardium; tuberculosis of lymphatic glands, as the retro- 
peritoneal and cervical; amyloid changes in liver, spleen, kid- 
neys and intestinal mucous membrane; fatty infiltration and 
enlargement of the liver, and endocarditis. 

Clinical Course. — In the vast majority^ of cases it is utterly 
impossible to clearly recognize the onset and the first symptoms 
of the disease. In almost every case a state of ill-health, with 
sy^mptoms pointing now here, then elsewhere, has existed for a 
considerable period of time before some indication of pulmonary 
trouble calls attention to the possible existence of a tuberculous 
lesion, without even then, by physical signs or otherwise, 
affording ground for a positive diagnosis. In many of these 
cases symptoms of dyspepsia, with loss of flesh and energy, and 
often pronounced anaemia, are the first evidence of failing 
health; in others, chills and fever annoy the patient for a long 
time, and in a malarial district are easily- attributed to malarial 



TUBERCULOSIS. 231 

poisoning; or the patient has long suffered from catarrhal 
trouble, has had a neglected cold, with, probably, symptoms of 
subacute bronchitis, cough, and tendency to asthma, all of 
which have been a source of trouble, but not sufficient to seri- 
ously alarm him or his physician; or an attack of pleuritis has 
left its victim with suspicious symptoms which eventually prove 
of tuberculous origin. In still other cases a. pulmonary haemor- 
rhage has occurred, the patient possibly being in apparently 
rugged health at the time, and a period of perfect well-being 
may have elapsed since his lungs have begun to trouble him. 
Or such laryngeal symptoms as huskiness or partial loss of 
voice bring to the consultation room of the physician what 
proves a case of laryngeal phthisis, with rapidly developing 
pulmonary symptoms. 

Local Symptoms. — Pain is usually of apleuritic character; it 
is felt in the lower part of the chest, under the scapula or, more 
rarely, at the apex; it may be quite constant, or occur at long 
or short intervals, or may be wholly absent. Cough in the 
great majority of cases is a prominent symptom throughout 
the disease; occasionally some patient suffering from phthisis 
rarely coughs. At first it is a dry, slight, hacking, bronchial 
cough; later, after cavities have formed, it becomes paroxysmal, 
occurring more often in the morning or at any time after lying 
down and when waking from sleep. In advanced cases it 
grows more troublesome and continuous, often exhausting the 
strength of the patient, particularly when associated with 
much pain; frequently it provokes vomiting and upsets diges- 
tion; in many cases it sadly interferes with sleep at night. — 
Sputum. During the early stage the sputum is catarrhal, of 
glairy appearance, and resembles sago, from the presence of 
alveolar cells which have undergone myeline degeneration. 
Later, small, greenish-gray masses are expectorated, which it 
is well to examine microscopically. The expectoration becomes 
purulent and profuse as the lung-tissue softens, and eventually 
assumes the "nummular" form, isolated, grayish-green masses 
■which at once sink to the bottom of a vessel containing water 
and constitute a proof of cavity formation. In exceptional 
cases no sputum is expectorated, even though there are physi- 
cal signs of tissue-consolidation. 

Microscopic examination of the sputum will determine the 



232 SPECIFIC INFECTIOUS DISEASES. 

presence of the bacillus of tuberculosis, and thus firmly establish 
the specific nature of the disease. Ehrlich's method, described 
on a preceding page, is very satisfactory. Dr. Heneage Gibbes 
recommends the following as well adapted to rapid work for 
diagnostic purposes: take of -rosanilin hydrochloride two 
grammes, methyl blue one gramme; rub them up in a glass 
mortar, then dissolve anilin oil 3 c.c. in rectified spirit 15 c.c; 
add the spirit slowly to the stains until all is dissolved, then 
slowly add distilled water 15 c.c; keep in a stoppered bottle. 
To use the stain: The sputum having dried on the cover glass 
in the usual manner, a few drops of the stain are poured into a 
test tube and warmed; as soon as steam rises, pour into a 
watch-glass, and place the cover-glass on the stain. Allow it 
to remain for four or five minutes, then wash in methylated 
spirit until no more color comes away; drain thoroughly and 
dry, either in the air or over a spirit lamp. Mount in Canada 
balsam. The whole process, after the sputum is dried, need not 
take more than six or seven minutes. This process is also valu- 
able for sections of tissue containing bacilli, as they can be 
doubly stained without the least trouble. Regardless of the 
method employed, repeated examinations are often necessary 
to prove the presence of bacilli. 

Elastic tissue is derived from the bronchial, alveolar, or from 
the arterial coats; if bronchial or alveolar, it indicates extensive 
erosion of the tube and softening of the pulmonary tissue. It 
is usually examined by boiling a quantity of the sputum in 
caustic soda solution for fifteen or twenty minutes or until 
liquefaction has taken place. As the solution is allowed to 
settle in a conical glass, the elastic fibre will fall to the bottom 
and, upon removal with pipette, is easily recognized under low 
power. Osier recommends as equally satisfactory the method 
of Sir Andrew Clark, which depends upon "the fact that in 
almost all instances, if the sputum is spread in a sufficiently 
thin layer, the fragments of elastic tissue can be seen with the 
naked eye. The thick purulent portions are placed upon a glass 
plate fifteen b3 r twenty centimetres and flattened into a thin 
layer by a second glass plate ten by ten centimetres. In this 
compressed grayish la^^er between the glass plates any frag- 
ments of elastic tissue show on a black background as grayish- 
yellow spots and can either be examined at once or under a low 



TUBERCULOSIS. 233 

power, or the uppermost plate of glass is slid along until the 
fragment is exposed, when it is picked out and placed upon the 
ordinary microscopic slide." The elastic tissue from the bron- 
chial tubes is seen in long narrow fibres, close together, or in an 
elongated network; the tissue from the blood vessels often pre- 
serves its easily recognized form; otherwise it appears not unlike 
the bronchial elastic tissue; that of the alveolar walls is branched 
and often preserves the original form of the cells. Blood and 
various fungi may also be shown under the microscope. 

Haemoptysis may occur long before the existence of a serious 
pulmonary lesion is suspected, and is a common feature of well- 
pronounced cases. The doctrine formerly held that pulmonary 
tuberculosis is often a sequel of haemorrhage has been discarded, 
and it is now generally held that the bleeding from the lung is 
in itself presumptive evidence of serious. pulmonary disease. If 
the blood is found mixed with the mucoid expectoration, its 
source is a congested bronchial mucous membrane or actively 
congested lung-tissue; if it is clear and occurs in considerable 
amounts, it is due to the erosion of a blood vessel or to rupture 
of an aneurism in a cavity, the amount of the haemorrhage in- 
dicating the size of the eroded vessel. Dyspnoea, if well pro- 
nounced, is the result of active and rapidly advancing broncho- 
pneumonia or of the invasion of a large area of lung tissue by 
miliary tubercles. But very extensive involvement may exist 
without much difficulty of breathing or great frequency of the 
respiratory movements. "One reason why there is so little 
shortness of breath in phthisis is that there is always a moder- 
ate grade of anaemia, and the diminished lung space is sufficient 
to supply oxygen to the reduced number of blood corpuscles." 

General Symptoms. — Fever is usually present throughout 
the course of the disease, though even here exceptions to the 
general rule are by no means infrequent. The fever is fitful, and 
nothing short of the constant and frequent use of the clinical 
thermometer can accurately keep track of it. It is of various 
types, intermittent, remittent, sometimes continuous; if the 
latter, remissions are common. The intermittent character of 
the fever is sufficiently pronounced to lead, often, in malarial 
districts, to the mistaken diagnosis of malarial fever. The fact 
that all stages of tubercular disease may, and do, simultane- 
ously exist in the affected lung explains the occurrence of differ- 



234 SPECIFIC INFECTIOUS DISEASES. 

ent types of fever at the same time. During the onset the fever 
is fairly continuous, but slight remissions are sure to be present. 
Later the remissions are less marked, particularly so when the 
disease is making rapid progress. When suppurative processes 
and systemic infection become a prominent feature of the case, 
pronounced intermissions and a subnormal temperature for a 
part of the time are present (hectic fever). Acute pneumonic 
processes, such as often occur in the course of phthisis, cause a 
persistent elevation of temperature, with only slight remissions, 
not more than one degree. The maximum temperature is com- 
monly reached in the afternoon, from 2 to 6 p. m.; the minimum 
temperature in the morning, between 2 and 6 a. m. Night- 
sweats are frequent, and are dreaded by both patient and phy- 
sician. They occur at night or while the patient is asleep, are 
drenching, and not only give rise to discomfort, but often to 
severe chilling. The pulse is frequent, soft, and lacking in 
volume; its rapidity^ depends in a measure upon the degree of 
pyrexia present. Emaciation is marked and progressive. A 
gain in flesh and weight in a phthisical patient is an encourag- 
ing sign. The nervous system may be seriously affected. 
Tuberculous lesions occasionally involve the brain, giving rise 
to a variety of disturbances the exact nature of which depends 
upon the part of the brain involved; cerebro-spinal meningitis 
occurs rarely. The mind of the consumptive is usually clear to 
the last; hopefulness is almost characteristic of the disease. 
Insanity may develop in chronic cases, usually in those well 
advanced. Among the gastro-intestinal symptoms the most 
noteworthy, and from a clinical aspect the most troublesome, 
is diarrhoea, depending upon a catarrhal condition of the in- 
testinal mucous membrane, or the result of anryloid degenera- 
tion, or of tubercular ulceration. Gastric disturbance is chiefly 
expressed by- loss of appetite, fitfulness in eating, often nausea 
and ver\ r persistent vomiting. The latter, when present, con- 
stitutes a distressing feature of the disease; it may be due to 
central causes, to pressure on the vagi, to stimulation from 
the peripheral branches of the vagus, or to mechanical causes. 
Tubercular infection may occur at almost any point, and cause 
much trouble; witness the sore throat and difficult}' of swallow- 
ing caused by tuberculosis of the larynx. — The circulatory sys- 
tem. Involvement of the left upper lobe of the lung leads to 



TUBERCULOSIS. 235 

exposure of a considerable surface of the heart, and if there is 
much retraction of the lobe, the heart may be drawn upward. 
There may then be pulsations in the second, third and fourth 
interspaces, near the sternum. Apex murmurs are often pres- 
ent; they may be harsh and rough, even when there is no endo- 
carditis. Systolic murmurs are common in all stages. The 
heart itself is often involved. Osier records twelve instances of 
endocarditis in 216 autopsies. Capillary pulse is at times 
noted, and pulsation of the veins in the back of the hand may 
be observed. Chloro-anasmia is common. — The genito-urinary 
symptoms. Albumin in the urine may be due to fever or to 
organic changes in the kidneys, as amyloid disease. Sometimes 
a condition closely resembling chronic Bright' s disease is pres- 
ent. Pus, bacilli or blood are occasionally found in the urine, 
especially when there is ulceration. — The skin tends to become 
dry and harsh, and local tubercles are sometimes seen on the 
hands. Pityriasis versicolor is not infrequently observed on 
the chest and back, as well as chloasma phthisicorum, pig- 
mentary staining. Clubbed fingers and toes, -with "claw-like, 
in-curving nails" and oedema of the feet and legs, due to femoral 
thrombosis or weakness of the heart, are common in the later 
stages. 

Laryngeal tuberculosis and pneumothorax are also to be 
mentioned; the former is of comparatively frequent occurrence 
after the lung has become extensively involved, and may 
usually be considered a very unfavorable symptom at any 
stage of the disease; the latter is caused by the bursting of a 
cavity into the pleural sac. In women menstruation is fre- 
quently suspended, quite early in the case of young women; 
more often the suppression of the menses is due to the physical 
exhaustion which is a feature of the advanced disease. En- 
largement of the mammary gland, especially in males, has also 
been noticed; according to Allot, it is a chronic interstitial, 
non-tuberculous mammitis. 

Physical Signs. — A satisfactory examination of the chest 
does not only include a knowledge of the physical signs to be 
looked for, and their ready recognition, but a carefully trained 
judgment which is the result of large clinical experience. The 
young physician, unless he has had unusual opportunities, 
should often and carefully examine the chests of presumably 



236 SPECIFIC INFECTIOUS DISEASES. 

healthy persons, for the sake of noting the sounds obtained by 
percussion and auscultation and of so training the ear that it 
will recognize them and differentiate between them. Thus 
normal and abnormal sounds will eventually be distinguished 
with readiness and interpreted correctly. 

Inspection. — The unreliability of the shape of the chest as an 
indication of existing phthisis, in the early stage, is now gen- 
erally understood. However, any considerable flattening in 
the upper thorax, especially in the supra- and infra-clavicular 
region, should be noted, and the chest-expansion carefully ob- 
served. Flattening on one side, above or below the clavicle, is 
a suspicious symptom. Palpation, in the early stage, will 
confirm the existence of deficient chest-expansion. There is in- 
crease in the vocal fremitus, of importance when on the left 
side. Percussion: The value of this method depends largely 
upon an exact comparison of the sounds obtained on both 
sides, remembering that on the right side the pulmonary reso- 
nance is less marked than on the left, and that the "pitch" of 
the percussion sound on the right side is higher. The extent 
and depth of the consolidation naturally affects the percussion 
sounds. If slight and superficial, the percussion sound will be 
raised; if deep and protected by healthy or emphysematous 
tissue, lying between the chest wall and the consolidated tissue, 
the percussion sound may be normal or very resonant. Flint 
states that in doubtful cases the percussion should be performed 
at the end of a full inspiration and of a full expiration. In- 
creasing consolidation causes increasing rise of the pitch of the 
sound and diminishing clearness, until, in some cases, absolute 
dullness is reached. Auscultation: The respiratory sound in 
the affected region varies. It may be weak or suppressed at one 
point, exaggerated at another, often jerky, "cogged-wheel," 
or coarse and bronchial. The inspiratory sound is high-pitched 
and tubular; the expiratory sound still higher in pitch and 
"lingering." "The value of these states of the respiration cor- 
responds to their position. If they exist above and are imper- 
ceptible below the second interspace, they are seriously signifi- 
cant. Localized mucous or sub-crepitant rales, heard over a 
limited space at the apex of the lung, are always important 
signs of tuberculosis and indicate the development of broncho- 
or catarrhal pneumonia. They are often present before any 



' 4k. 
TUBERCULOSIS. 237 

appreciable change in the respiratory murmur occurs. At first 
they are more or less obscure in proportion to the weakening of 
the respiration; gradually they become more distinct and 
numerous as the pulmonary consolidation increases. The 
heart sounds over the affected lung will be increased in inten- 
sity." (Flint: Physical Diagnosis.) — There may also be exag- 
gerated vocal resonance at the left apex. 

The advanced stage presents much more distinctive signs. 
Inspection now shows general contraction of the chest walls, 
corresponding to the destruction of lung tissue and resulting 
shrinkage in the volume of the lung. The infra- and supra-clavic- 
ular depressions are marked, expansion is notably diminished, 
possibly arrested near the apex, and there is increase in the fre- 
quency of respiratory movements. Palpation yields, usually, 
increase of vocal fremitus over the area of consolidation, some- 
times gurgling fremitus. Percussion: Extensive and marked 
dullness prior to the formation of vomicae. The cavity having 
formed, and being of small size, and lying within an area of 
consolidated tissue, the percussion sound is dull or tubular; if 
the cavity is full and protected by a layer of healthy tissue, 
percussion must be forcible to yield the characteristic dullness. 
If the cavity is large, empty, superficial, and thin-walled, the 
"cracked-pot" sound is heard. Auscultation: Consolidated 
tissue yields bronchial, moist, crackling, metallic rales, some- 
times "lingering" or "sticky," not affected by coughing. In- 
tense bronchial breathing and intensely metallic moist sounds 
are usually heard at the seat of the cavity. Cavernous sounds 
are heard in an empty, superficial cavity in communication 
with a bronchial tube, the cavity walls collapsing and expand- 
ing with each inspiration. Amphoric sounds, resembling the 
sound "heard on blowing into a decanter," are produced if the 
cavity is large and surrounded by any firm structure which pre- 
vents collapse during inspiration. Gurgling sounds are caused 
by the accumulation of fluid in a cavity, sufficient to rise above 
the opening into it. Small cavities, partly filled and deep- 
seated, yield gurgling sounds which it is difficult to distinguish 
from mucus rales. Vocal resonance rarely is of positive value. 
It may be absent or weak, amphoric or bronchophoric; or there 
may be pectoriloquism. 

It must not be forgotten that, especially in the early stage, 



238 SPECIFIC INFECTIOUS DISEASES. 

many of the signs are best heard behind and that, owing to the 
complexity of the lesions which may exist in the same lung, a 
puzzling variety of the signs described may be detected. 

FIBROID PHTHISIS. 

Fibroid phthisis is a sclerosis of the lung tissue, with gradual 
shrinkage, resulting from chronic tuberculous broncho-pneumo- 
nia or chronic tuberculous pleurisy, sometimes also occurring 
as a feature of ulcerative phthisis. The process is identical 
with chronic interstitial pneumonia or cirrhosis of the lung. It 
usually affects the apex of one lung. A dense fibrous formation 
surrounds a cavity; the pleura becomes thickened, gradually 
the affection invades the lower lung, with shrinkage and retrac- 
tion of the diseased lung and displacement of the heart, and oc- 
casionally of the liver, toward the affected side. 

The disease is characterized b}' paroxysmal cough, worse in 
the morning, purulent expectoration, very offensive when bron- 
chiectasis is pronounced, some dyspnoea, and slight, if any, 
fever. There is dilatation of the bronchi and hypertrophy of 
the right ventricle or of the entire heart. Bacilli or evidence of 
tuberculous infection are usually found in advanced cases. 
Haemorrhage may occur from an aneurismal sac in a cavity. 
The physical signs observed are a sinking of the chest wall on 
the affected side, with dropping of the corresponding shoulder, 
and symptoms which are due to the displacement of the heart, 
as heart murmurs and cardiac pulsations in the third, fourth, 
and fifth interspaces, if the left lung is involved. The various 
sounds due to the formation of cavities, the degenerative 
changes in other organs which follow chronic suppuration, and 
dropsical conditions, depending upon heart-failure, are added to 
the signs which are incidental to the process. 

Fibroid phthisis is essentially a chronic disease, and may con- 
tinue from three or four to twenty, or more, years. 

Diagnosis of Pulmonary Tuberculosis. — It is obvious that 
much depends upon a prompt recognition of this disease in its 
early stage. No effort should be spared to determine the na- 
ture of the complaint and, this accomplished, to impress upon 
the mind of the patient the gravity of the situation. It is well 
known that consumptives are, as a rule, unwilling to believe 



TUBERCULOSIS. 239 

that they are in danger, and insistence on part of the physician 
may expose him to unmerited suspicion; but it is by far best to 
ignore the latter and to be unconditionally frank, thus placing 
the full measure of responsibility upon the patient and his 
family. 

The value of the microscope as a means of diagnosis has been 
emphasized, and the mode of procedure in examining for the 
bacillus tuberculosis has been described. It must be remem- 
bered that in about thirty per cent, of cases repeated examina- 
tions are required to establish the presence of the bacillus, and 
that even failure does not necessarily disprove a diagnosis of 
tuberculous phthisis. Inoculation for diagnostic purposes has 
of late received much attention. 

Among the many symptoms of phthisis few are of more pos- 
itive diagnostic value than the fact that the earliest signs are 
almost invariably observed at the apices. 

Chronic Bronchitis resembles the early stage of pulmonary 
tuberculosis before tissue-consolidation has taken place. Bron- 
chitis, however, is a bilateral disease, lacks the profound consti- 
tutional symptoms of tuberculosis and, usually, presents well- 
defined and characteristic physical signs. In the absence of 
bacilli, under microscopic examination, the diagnosis must be 
guarded until light is thrown upon the case by the development 
of later and positive symptoms. — Chronic Pleurisy, with effu- 
sion, in many respects bears a much closer resemblance to 
phthisis, including cough, dyspnoea, emaciation and, if pus be 
present, even hectic fever. In pleurisy, however, the area of 
dullness extends from below upward, and there is an absence of 
the respiratory sounds which are characteristic of phthisis. 
"The other signs over the lower part of the chest also, the ab. 
sence or diminution of respiratory sounds, of vocal resonance 
and fremitus, etc., unite in proclaiming the collection of fluid. 
When this collection is sufficient to solidify, it may be in some 
cases for a time difficult to decide whether we have a case of 
pleuritic effusion alone or of one complicated with phthisis, the 
sign of solidification at the apex, either from compression or 
from tubercular deposits, being pretty much the same. If, how- 
ever, as is often the case with the latter trouble, rales are also 
present at the apex, if the emaciation and the hectic are par- 
ticularly well marked, aspiration showing no pus in the pleural 



240 SPECIFIC INFECTIOUS DISEASES. 

cavity and the temperature ranging from 100° to 103°, and if 
haemoptysis has occurred, we have very strong reasons for sus- 
pecting the complication. This will be reduced to a certainty if 
after a while a tubercular deposit is found, by its physical 
signs, to have taken place at the other apex. If, after the rad- 
ical operation for empyema, with daily washing out of the 
pleural cavity, the temperature does not fall to nearly the nor- 
mal, phthisis in connection may be suspected. If the pleuritic 
trouble affects both sides of the chest, a phthisical complication 
is exceedingly probable." (H. C. Clapp.)— Acute croupous pneu- 
monia affects by preference the lower lobe or the whole lung, 
but it may involve the apex; if so, the diagnosis presents diffi- 
culties and rests largely upon the history of the case. Pulmo- 
nary cancer is usually a secondary affection, and the existence 
of cancer in any other part of the body is strongly presumptive 
evidence of the cancerous nature of an incidental pulmonary 
lesion. If primary, one side, usually, is invaded; but the ab- 
sence of special preference for the apex, the comparative slow- 
ness with which the cancerous tissue breaks down, the jelly-like 
expectoration, the less rapid emaciation, the continuously severe 
pain, as compared with the absence of pain or the pleuritic 
pain of tuberculosis, will establish the nature of the disease. 
Pulmonary abscess after pneumonia usually affects the lower 
lobe of one lung, and has a characteristic penetrating, unmis- 
takable fetor of expectoration. Pulmonary gangrene involves 
the lower lobe of one lung, the expectoration is horribly fetid, 
the breath almost equally so, the sputum is of a dark, brownish 
color, and broken-down tissue occurs in abundance. Pulmonary 
syphilis is rare, generally affects the base or the lower part of 
the upper lobe, progresses rather slowly, and has a history of 
syphilitic infection. Bronchiectasis cannot always be recog- 
nized. It has the physical signs of a cavity, but the area of 
dullness is more limited. The expectoration is more copious 
and fetid, and occurs in connection with paroxysms of cough- 
ing which are usually brought on by a change of position and 
take place at long intervals, with prolonged periods of freedom 
from cough between them. Marked embarrassment of the 
pulmonary circulation is frequently present. 

Prognosis. — The prognosis, as to complete recovery, is unfav- 
orable. That the disease is often indefinitely arrested, even in 



TUBERCULOSIS. 241 

unpromising cases, the patient eventually dying from some 
other cause, is shown in the experience of every practitioner and 
by an abundance of evidence obtained post mortem. Removal 
to some suitable climate is not infrequently followed by great 
improvement and by an arrest of the disease; such improve- 
ment may often be maintained for years, and life and useful- 
ness correspondingly prolonged, by making the change of cli- 
mate permanent. 

A continuous lowering of the temperature, lessening of ner- 
vous tension, and gain in weight may be considered favorable 
symptoms; the reverse, of course, obtains. Gastro-intestinal 
and laryngeal complications are always unfavorable. Fistula 
in ano and haemorrhoids very often complicate tuberculosis, 
and it is undoubtedly true that in either case an operation, 
though in some respects affording the patient relief, is followed 
almost invariably by an aggravation of the general condition 
and materially hastens the fatal termination. 

Death occurs from asthenia, and may be peaceful to the last 
degree, consciousness being retained to the very last; or from 
syncope, as after severe haemorrhage or in connection with or- 
ganic cardiac disease; or from asphyxia, especially in acute 
miliary tuberculosis, rarely in the chronic form; or from haem- 
orrhage due to erosion of the coats of a large blood-vessel or 
the bursting of an aneurism; or from cerebral causes, as coma 
due to meningitis. 

TREATMENT OF PULMONARY TUBERCULOSIS. 

Prophylaxis: Marriages should not be contracted between 
parties of phthisical predisposition, and this prohibition 
should be enforced more rigorously in the case of a "woman than 
of a man, for statistics plainly prove that consumption is in- 
herited through the mother oftener than through the father. 
While under appropriate treatment a girl's health may improve, 
pregnancy and child-birth, with the subsequent task of suckling 
and caring for the child, will so lower her vitality that she can 
neither maintain her own health nor supply proper nourish- 
ment or care to the infant. 

The child born, every means must be employed to prevent ex- 
posure to infection and to cultivate to the utmost everything 
16 



242 SPECIFIC INFECTIOUS DISEASES. 

that promises to give it a rugged constitution— for that means 
power to resist disease. The former consists of careful protec- 
tion against close contact with the products of the disease, and 
chiefly implies the common precautions on part of consumptives 
not to expectorate carelessly, to promptly destroy the sputum, 
and not to infect others by kissing them. 

The danger of inhaling pulverized dust containing the bacilli 
of tuberculosis has been discussed, and is quite fully realized by 
the profession and by the intelligent laity. It is, therefore, only 
just to insist that consumptives shall take pains not to become 
a source of danger to others. If cuspidors are used, they 
should contain a 5 per cent, solution of carbolic acid in water, 
and should be frequently emptied and thoroughly cleansed and 
disinfected. Paper cups, supported by a metal rim, are now 
generally sold, and are both convenient and inexpensive. If 
the patient is too ill to raise his head from the pillow, paper 
handkerchiefs may be used and then burnt at once; cloths and 
towels, used for the same purpose, must be immediately de- 
stroyed. 

The habit of expectorating upon .the sidewalk, streets, or into 
the gutter, is both disgusting and dangerous. Detweiler's flask 
makes this practice unnecessary. "It is made of blue glass, is 
flat, and holds about three fluid ounces. There are two open- 
ings, one at the top and one at the bottom, both having me- 
tallic screw-caps. The upper opening, which is the larger, has 
in addition a spring cover or lid which closes tightly; also a 
polished metal funnel which reaches half way down into the 
flask." This funnel prevents the spilling of the contents even if 
the flask is left open; the lower opening aids in giving it a 
thorough cleansing. Its use should be made obligatory. 

If the mother is consumptive, the infant should be nursed by 
a healthy foster mother, or, if that is not possible, should be 
"brought up by hand"on the milk of a carefully selected cow 
or goat. The animal thus selected should have the greatest 
freedom possible, and its feed and stabling should be made the 
object of close care. Sterilization and boiling of the milk has 
its warm advocates, but there are objections to both; it is ad- 
visable in the city. If the child prospers, weaning should be 
postponed as long as possible. 

Inunctions of olive oil, cocoa-nut oil, or cod-liver oil, warmed 



TUBERCULOSIS. 243 

and persistently applied over the abdomen, may be used if the 
child does not thrive under the treatment outlined, and artifi- 
cial foods, malted milk, and other standard preparations, may 
be tried; the bowels in the meantime must be kept open by the 
indicated remedy or by the judicious use of the enema. 

The cool bath, once or twice a day, followed by friction and 
massage, is helpful. "Taking cold" must be painstakingly 
avoided, and to that end the child must be clothed properly, 
not too warmly. Light woolen undergarments are particu- 
larly suitable. Jaeger's underwear and the "Jaros Sanitary 
Wear" are the best that can be obtained. With it all, the child 
must not be "babied" too much. The throat and chest should 
often be sponged in cool water and the little one made to live 
out in the open air when the weather permits, even if the day is 
cool. While in the house, the nursery should not be overheated; 
a temperature above 70° F. is objectionable; if the heat in the 
room is dry, moisture must be provided by placing upon the 
stove or radiator a small vessel containing water. Draughts 
and sudden changes of temperature are dangerous. 

With advancing years, many difficulties are removed, while 
others increase. The diet should be wholesome, not too stimu- 
lating; if digestion is not good, it must be improved by judi- 
cious management and the use of proper remedies rather than 
depend upon peptonized and specially prepared foods. Proper 
clothing; a sufficiency of sleep; a life in the open air, with an 
abundance of sunshine; moderate hours in the school room; 
healthful moral tone; in due time proper instruction in sexual 
hygiene and judicious preparation for a normal adolescence, — 
all these are of far-reaching importance, and worth the per- 
sonal attention of parents and physicians. 

Unfortunately, many conditions which are absolutely neces- 
sary for the modification or eradication of the susceptibility to 
phthisis can only be met if the parents are in comfortable cir- 
cumstances. Thus, among the very poor it is almost useless to 
talk of "sanitary conditions" save as enlightened public pol- 
icy finds a way of providing them. But large, well-ventilated 
rooms, dry and airy, with an abundance of breathing space; 
pure wholesome water ; wholesome food ; and, above all, resi- 
dence in a climate both bracing and free from extremes of tem- 
perature, are wonderful agencies in toning up a naturally 



244 SPECIFIC INFECTIOUS DISEASES. 

feeble constitution and in eradicating an inherited predisposi- 
tion to tuberculous affections. 

Should symptoms of pulmonary involvement actually show 
themselves, the most pressing consideration is that of climate. 

Climatology is so extensive a subject, and our knowledge of 
it is as yet so limited and unsatisfactory, that it will be dis- 
cussed very briefly. This may prove the more practical since 
no one spot on earth, no matter how favored it may be, com- 
bines all the conditions which constitute an ideal climate or 
meets the requirements of more than a small number of cases. 
Additionally, I am influenced by the belief that little benefit is 
derived from a change of climate unless the change is pro- 
tracted or permanent and does not include, as it most always 
does, a surrender of home and home comforts, and a separation 
from all that makes life precious, including every familiar voice 
and every loved face. 

The chief conditions to be met are: equability, comparative 
dryness of the air, abundance of sunshine, dryness and good 
drainage of the soil, pure water, absence of violent atmospheric 
disturbances, and proper altitude. To these may be added cer- 
tain minor considerations, such as beauty of scenery, cheapness 
of living, nearness to some large town which provides means of 
amusement, opportunities to bathe, fish, swim, drive, ride, 
hunt, — conditions which add to the pleasure of living and con- 
stantly hold out inducements to pass the time in the open air. 

It is safe to affirm that many points in America, and these 
alone will be considered, possess to a large degree many or all 
these features. Yet, each point has its special advantages and 
disadvantages, and to select for any individual case the climate 
best suited to the stage of the disease and to the particular 
need of the patient is a task of some magnitude, often only 
settled by actual and persevering trial. It is remarkable with 
what readiness medical men undertake to pose as authorities 
on the subject of climate from observations gathered on a fly- 
ing trip through the country, often passing a very few da} T s in 
a locality upon whose climatic features they write extensive 
articles, when physicians on the ground are forced to confess 
that each day's additional observation increases their caution 
in making claims to special knowledge save as it is expressed in 
very general propositions. In fact, a climate selected for the 



TUBERCULOSIS. 245 

very best reasons as peculiarly suitable for a certain patient 
often proves the reverse; and it is no infrequent occurrence to 
have a patient do well at a point which at first glance seems 
little adapted to his needs. It is partly on this account that no 
invalid should be allowed to assume the responsibility of decid- 
ing for himself, but should be referred to a local practitioner of 
intelligence and candor whose decision must be final. 

C.J. B.Williams and C.Theodore Williams, excellent authori- 
ties on the relation of climate to the cure of consumption, lay 
down the following general rules: High-altitude stations are 
most beneficial for cases of (1) marked hereditary predisposi- 
tion in which phthisis is either threatened or in a state of early 
development; (2) imperfect thoracic or pulmonary develop- 
ment; (3) hemorrhagic phthisis; (4) chronic pneumonia, with- 
out bronchiectasis, which does not resolve; (5) chronic pleurisy, 
where the lung does not expand after removal or absorption of 
the fluid; (6) phthisis accompanied by more or less pneumonic 
consolidation; (7) chronic tubercular phthisis in its various 
stages, provided the lung surface be not too strongly involved 
to admit of proper respiratory change at the high altitude, and 
there be no pyrexia. 

Mountain climates are counter-indicated in cases of (1) em- 
physema and phthisis with emphysema; (2) chronic bronchitis 
and bronchiectasis; (3) diseases of the heart and great vessels; 
(4) affections of the brain and spinal cord and states of hyper- 
sensibility of the nervous system; (5) diseases of the kidney 
and liver; (6) diabetes; (7) catarrhal phthisis; (8) phthisis 
with double cavities, with or without pyrexia; (9) all cases of 
phthisis in which the pulmonary area is too largely encroached 
upon to admit of the proper performance of the respiratory 
function; (10) cavity cases with profuse haemoptysis, pointing 
to the probable existence of a pulmonary aneurism; (11) cases 
of phthisis with great irritability of the nervous system; and 
(12) patients advanced in years or too feeble to take exercise. 

The cases best suited for sea-voyages are: (1) hemorrhagic 
phthisis; (2) scrofulous phthisis, especially where fistula has 
developed; (3) cases of limited consolidation or cavity, where 
without pyrexia the cough is hard and obstinate, probably 
from bronchial involvement; (4) cases of phthisis with emphy- 
sema; and (5) cases of limited tuberculous disease in patients 
who have been overworked in mind and body. 



246 SPECIFIC INFECTIOUS DISEASES. 

Climatic changes are without influence in cases of acute 
tuberculosis, tuberculo-pneumonic phthisis, laryngeal phthisis, 
acute phthisis, except in a few instances where the intensity of 
the tuberculous process has been reduced by extensive exuda- 
tion and has passed into quiescence; also cases accompanied 
with continuous pyrexia, or in which the process of tuberculiza- 
tion or excavation is actively proceeding, and advanced 
phthisis accompanied by intestinal ulceration and diarrhoea. 

H. C. Clapp points out that "it is particularly important to 
remember that change of climate is a relative term, and that to 
receive benefit from it there is by no means always the necessity 
for travelling to the ends of the earth or to a great distance. 
Often only a few miles, or possibly a few rods, from a valley to 
a hill-side, from a swampy neighborhood to a dry, gravelly 
soil, may be sufficient. This fact is too often forgotten, but has 
been repeatedly proved." 

The South presents many attractions to those inclined to 
consumption; these depend largely upon the accessibility of the 
country and its warm, genial winters. Cases of severe bron- 
chial affection and imperfectly resolved cases of pneumonia do 
nicely there. The local conditions, however, are not always 
favorable in well-established phthisis, the patients often suffer- 
ing from debility, the result of the heat and moisture frequently 
found there, and the malarial influences which are at work 
under these conditions. This applies particularly to Florida. 
Its nearness, however, to the northern states, the ease with 
which its resorts are reached, and the many attractions 
offered by them, makes Florida and some portions of Texas, as 
San Antonio, of the greatest value to those who require little 
more than an escape from the severity of a northern winter 
and spring. Aiken, South Carolina, is located on a high, sandy 
ridge, has an even, warm temperature, and is surrounded by 
groves of pine which render the air very grateful to persons 
with weak lungs. Of late years excellent hotels have been 
built for the convenience of invalids, and, with the exception of 
occasional severe north-easters, the locality possesses many 
features which commend it highly. Georgia has a compara- 
tively dry atmosphere and varying altitude, and to the patient 
who is able to endure "roughing it," offers an agreeable and 
healthful change; the Cumberland Table Lands, in Eastern 



TUBERCULOSIS. 247 

Tennessee, has similar advantages, and for its natives there is 
claimed an almost complete exemption from consumption. 
Minnesota has an even, dry, cold climate, with moderate rain- 
fall and elevation, and an abundance of spruce and pine; its 
summers are hot and sudden changes of temperature are 
common. The Adirondacks, in New York, and the White 
Mountains, in New Hampshire, offer similar advantages. Un- 
doubtedly, an open-air life in these regions has decidedly bene- 
ficial effects, and a long season spent in them will prove helpful 
to those who, chief of all, must get away from the confinement 
and excitement of business life, and who, if inclined to phthisis, 
have as yet no extensive involvement of lung tissue and possess 
sufficient vitality to endure a considerable amount of exposure 
and cold. All others run great risk from entering upon this 
sort of life. Residence in the Rocky Mountain region, more 
especially Colorado, has unquestionably prolonged the life of 
many consumptives. The greater portion of Colorado has an 
altitude ranging from 1500 to 11,000 feet, and more, above the 
level of the sea, an abundance of sunshine, and marked mild- 
ness and dryness of the atmosphere. Denver, Colorado Springs, 
Manitou, and other points, are favorite and charming resorts. 
Objections are the great difference between day and night tem- 
perature, frequent severe winds and clouds of dust (a recent 
writer points out the fact that high winds, and that means 
dust, are peculiar to all health resorts of established reputa- 
tion), and the high elevation of many of its most attractive 
and famous resorts. Wyoming, New Mexico, and Arizona have 
each their admirers, and deservedly so. All have dry, pure air, 
varying altitude, and during a portion of the year offer every 
inducement for an open-air life. Lack of facilities for the com- 
fort of invalids and frequent severe storms in the winter are 
objections to Wyoming as a permanent home for consumptives. 
These objections apply less forcibly to NewMexico. Las Vegas, 
Hot Springs, N. M., is a charming place, well sheltered, at an 
elevation of 6,700 feet above sea level, has a fine reputation as 
a summer resort, but is objectionable as a winter home. El 
Paso, is less than 4,000 feet above the sea level, has sandy, 
porous soil, and as a winter residence has proved of great 
benefit to persons suffering from asthma, bronchitis, and con- 
sumption. Throughout the state the atmosphere is dry, and 



248 SPECIFIC INFECTIOUS DISEASES. 

the sky almost cloudless; the heat at midday is very great, and 
the changes in temperature between night and day, monthly 
and yearly, are unpleasantly pronounced. It is stated upon 
good authority that the Indians of New Mexico suffer very 
little, if any, from consumption, and U. S. troops, stationed 
there during a period often years, from 1867 to 1876, had only 
two deaths from consumption among eighty-two men. Arizona 
possesses exceptional dryness and purity of the atmosphere, 
almost perpetual clearness of the sky, and very few rainy days; 
the country is mountainous and wild. Certain points, as old 
Fort Apache, are especially salubrious. The elevation ranges 
from 500 to 6,000 feet above sea-level. Patients who require 
dryness and warmth of the atmosphere, and who are strong 
enough to endure a rough life, will do nicely here. Some recov- 
eries from phthisis have been made in the late stage of the dis- 
ease, and Arizona will be\ r ond a doubt become a favorite resort 
for consumptives as soon as better provisions can be had for 
the comfort of invalids. Southern California is remarkable for 
the great variety of its climate within comparatively narrow 
geographical limits. The coast belt affords all the advantages 
of nearness to the sea without that rawness of the atmosphere 
which characterizes the Atlantic coast for a considerable por- 
tion of the year, and, to a remarkable extent, freedom from 
severe storms. Retiring inland, and beyond the immediate 
sweep of the continuously moving, gentle sea breeze, the heat 
increases and soon reaches the high average which belongs to 
the semi- tropics. The average temperature, at noonday, twelve 
miles inland, is probably twenty degrees higher than on the 
coast. The altitude also increases gradually, for the coast 
range of mountains follows the general outlines of the coast, 
sometimes closely approaching the sea, sometimes receding to 
a distance of fifty, or more, miles. Here delightful summers 
and cold winters, with quite pronounced changes of season, 
prevail, wholly at variance with the continuously even tem- 
perature near the coast, especially in the extreme south of the 
state. Still further eastward lies the desert, at an elevation of 
some 2,000 feet, hot and dry, with a day temperature of 100° 
to 110°, followed by nights so cool that heavy blankets are 
necessarA^ for comfort. The main chain of the Sierra also runs 
parallel to the coast, at a distance of 60 to 200 miles, rising to 



TUBERCULOSIS. 249 

an elevation of from 8,000 to 14,000 feet, with spurs which 
often touch the lower coast range, and form valleys and shel- 
tered nooks which by their varying altitude and exposure to air 
currents from the sea or to the warm desert winds fairly revel 
in differences of climate and of vegetation. "While upon the 
ocean side of the range are great forests where the giant red- 
wood is bathed nightly in the dense, cool fog which seems to be 
essential to its growth, just across the summit are warm 
mountain slopes facing off toward the morning sun, their roll- 
ing hills green to the very crest with the olive and the vine; and 
yet, from their sheltered warmth one may pass on for a few 
miles to some pass or gap in the range that is swept during all 
the summer months by the great, cool ocean wind as it rushes 
through to the heated interior. Thus, there is scarcely a point 
in California where one within a few hours by rail has not his 
choice of a climate varying from the heat of the Atlantic or 
Mississippi midsummer to the coolness of the White Mountains 
or the perpetual snows of the higher Alps; his choice from a hot, 
dry air, as of the highlands of Arabia, to fogs and coolness, as 
of the west coast of Scotland; his choice from a stillness, as of 
a calm of the 'hollow lotus land,' where no harsh winds blow, 
to other points swept by ocean winds which for months pour 
inland with the rush and the roar of a great aerial river. It is 
this infinite variety, lying back of the typical equability, which 
gives to the Pacific slope climate its strongest charm, and 
which makes it suit so infinite a variety of constitutions and 
diseases." (Drs. Lindley and Widney.) 

The rainfall in Southern California occurs in the winter 
months. It is no continuous rainy season, but three or four 
storms, preceded by some days of cloudy weather, and followed 
by beautifully sunny, clear days, furnish the necessary rain to 
bring out and maintain the luxuriant verdure of this southland. 
Fogs are not the chilling fogs of the Atlantic coast, but occur 
in the early morning hours, usually disappear shortly after 
sunrise, and only rarely annoy those who are especially sensi- 
tive to them. The range of humidity is very great. The aver- 
age at Yuma is 43; at San Diego, about 70; at Los Angeles, 
about 68; at New Orleans, about 79. In the interior valleys it 
is probably not far from 60. The average number of cloudy 
days in the year is about 40 in the interior, somewhat greater 



250 SPECIFIC INFECTIOUS DISEASES. 

nearer the coast. Violent windstorms are practically unknown, 
but a continuous breeze from the ocean cools the heated atmos- 
phere. It is largely due to this soft, cooling breeze that in the 
strip of country lying about the Bay of San Diego, in the ex- 
treme southwest of the United States, great heat in the sum- 
mer months is unknown, the majorriy of residents wearing the 
same weight and thickness of undergarments throughout the 
year. The temperature is remarkably even. The home of the 
orange and lemon must be without frost in the winter; and 
earth offers no more charming country for a summer residence, 
away from oppressive heat and violent storms, than the coast 
of southern California. The annual mean temperature of New 
York is 53.3°; that of Los Angeles, 60.5°; ^San Diego, 60.5°. 
The average in January is in New York, 30.0°; at Los Angeles, 
52°; at San Diego, slightly higher, 52.8°; in July, in New York, 
72.6°; at Los Angeles, 68.2°; at San Diego, slightly lower, 
66.9°. The daily range in January is in Los Angeles, 21.5°; at 
San Diego, 19.0°; in July, at Los Angeles, 28.3°; at San Diego, 
14.6°. 

But Southern California is not a paradise, and does not by 
any means restore health and life to every pilgrim in search of 
them. Here, as elsewhere, there are damp, cold, unhealthful 
localities, unfit for permanent residence and otherwise open to 
serious objections. Summing up the benefits derived from a 
residence in the state, it may be said that the}" depend upon the 
opportunity offered of living the entire year in the open air, in 
a sea of sunshine, in almost any altitude desired, with almost 
any degree of humidity needed, and beyond the danger arising 
from sudden, unexpected changes or extremes of temperature. 

Certain considerations should always be kept in mind when 
sending a consumptive away from home. The trip should not 
be postponed until the disease is too far advanced. It is useless 
to expect much benefit in a case where there is extensive break- 
ing down of tissue; death is the almost inevitable outcome, and 
death in a strange land, among strangers, is a hard fate from 
which the home physician should save the sufferer. Again, a 
consumptive should not go away from home unless he has the 
means to take advantage of the opportunities offered him. 
One too poor to have nourishing food, or to live in a room or 
house which affords the comforts,, as to warmth and sunlight, 



TUBERCULOSIS. 251 

which to the invalid are absolute necessities, had much better 
remain at home. The invalid should not be encouraged in the 
belief that he may dispense with medical advice. If ever needed, 
it is when away from home, in a country and under conditions 
entirely new to the patient; besides, if there is any advantage 
to be derived from the climate, the intelligent medical man is 
the one most likely to fully utilize it. The patient, if at all ad- 
vanced in phthisis, should not be allowed to think that a few 
months' residence in a salubrious climate will materially benefit 
him. There is rarely enough gain in a few months to warrant 
the fatigue of a long journey or the necessary expense. If a 
change of climate is really needed, that change includes a pro- 
tracted or permanent residence. 

As to Southern California, with its great distance from the 
east, additional considerations enter. The invalid is always 
strongly tempted to play the tourist, for there is much to be 
seen, and many a person has sacrificed his last chance by trav- 
eling from place to place, foolishly expending precious strength 
and recklessly incurring exposure which is incidental to all 
travel. The selection of the particular spot best adapted to the 
needs of the patient also offers difficulties which are best left to 
some reputable local practitioner whose knowledge of the con- 
ditions necessary to the welfare of the sick, even in the details 
of daily life, is invaluable to an invalid. 

Wherever a patient may find himself, at home or seeking the 
benefit of a change of climate, certain precautions must be 
taken. He must have an abundance of air; the house and 
rooms he. lives in must be kept well ventilated and not over- 
heated; a temperature of 65° is usually quite enough for a 
living-room, and 55° is not often too cool for the bedroom. If, 
however, more warmth is demanded, the patient's wish should 
be gratified. A cold, damp room is highly objectionable, espe- 
pecially near the seashore; consumptives living near the ocean 
must occupy a room with a southern or southeastern ex- 
posure, containing provision for heating it when the weather 
is chilly or the atmosphere damp. Draughts must be carefully 
avoided. Sunshine is heathful in any country, and is to be 
courted assiduously. Consumptives may find an inducement 
to do so in Koch's statement that tubercle bacilli are killed in 
from a few minutes to a few hours by direct exposure to sun- 



252 SPECIFIC INFECTIOUS DISEASES. 

light, and die in five to seven days in ordinary sunlight. As to 
clothing, it must be suited to the climate and season; invalids 
away from home will find woollen garments of proper weight 
the best for all purposes. One visiting Southern California 
should always, even in mid-summer, be provided with medium 
weight underwear; in the case of women, the thin summer 
goods so extensively used in the east are practically useless. 
Both undergarments and the outer dress must be high in the 
neck and long-sleeved. The throat and neck should not be 
especially wrapped, and chest-protectors and similar devices 
are not to be tolerated. However, extra wraps must always 
be at hand to prevent standing or sitting in a current of air 
without additional protection or for use toward evening, and 
at all times when driving. The matter of proper diet often 
constitutes an intricate problem. Usually it is safe to allow a 
patient absolute freedom, particularly in the majority' of ad- 
vanced cases where an attempt to prescribe a strict diet is 
often followed by a refusal to eat anything. Generally speak- 
ing, nitrogenous foods are most valuable; hydrocarbons come 
next, carbo-hydrates last. "The American custom of three 
stated meals daily is a good one. In addition, food should be 
taken at suitable intervals between the stated meals and at 
bedtime. Rarely more than three hours, never more than four 
hours, except during sleep, should elapse between the times of 
taking food; and not only should a glass of milk, cream, or 
milk-punch be taken just before going to bed, but there should 
be something of the kind, or perhaps a glass of wine or spirits, 
with some suitable meat-preparation, like liquid peptonoids, 
by the bedside within easy reach of the patient in case of 
waking during the night or early morning." Bathing, even in 
adults who are unaccustomed to it, must be practiced with 
some care to gradually inure the patient to the cold. Sponging 
in cold water each morning is commendable when it is kindly 
borne; the shower bath, and almost any other kind of bath, is 
useful if practiced intelligently and when grateful to the 
patient. But it is folly to insist upon making a routine treat- 
ment of bathing, for often it proves exhausting and mischiev- 
ous. Exercise in the open air, driving, riding, rowing, fishing, 
hunting, walking, swimming, calisthenics, etc., are also great 
helps, always provided that excess, especially' in the use of the 



TUBERCULOSIS. 253 

upper muscles of the body, is carefully avoided. A correspond- 
ing amount of rest must be enjoined, and everything done to 
insure an abundance of refreshing sleep at night and, if neces- 
sary, during the day. 

It requires good judgment and wise management to so regu- 
late the daily life of the patient as to look after all these details 
without being "fussy" and without making the invalid selfish 
and unreasonably exacting from persons with whom he is 
brought in contact. 

Local treatment, usually by means of air impregnated with 
medicinal agents, has been extensively practiced. The use of 
oxygen, compressed air, carbon dioxide, and similar substances, 
does not properly belong under this head, and will not be dis- 
cussed here because, like the specific treatment of Koch, it not 
only belongs to the field of the specialist who has extensive ap- 
paratus and facilities beyond the reach of the general practi- 
tioner, but because the results actually obtained are by no 
means reliable or encouraging. 

The same may be said of the treatment by sulphuretted hy- 
drogen, iodine, kreosote, and other agents inhaled. The im- 
provements occasionally had under their use are uncertain and 
too trifling, so far, to even form a valuable adjunct to the "in- 
dicated remedy." As antiseptics, beechwood kreosote, guaiacol 
and eucalyptus have proved of some service. They are used by 
means of a wire cloth inhaler, containing a sponge or cotton 
saturated with the medicine. Beech-wood kreosote is more fre- 
quently used. It is diluted with an equal quantity of alcohol, 
one drachm being required for an hour's inhalation. The 
phthisical cavity may be treated directly by a weak, antiseptic 
solution of kreosote or iodine, injected by means of a hypoder- 
mic syringe provided with a long needle. 

Treatment of Special Symptoms.— Cough constitutes one of 
the most persistent symptoms of -which the patient begs to be 
relieved. The annoyance and suffering resulting from the in- 
ability to control it are so great that often it is difficult to 
resist the patient's pleading for morphine or some agent that 
promises to give temporary relief. Readily admitting that 
laryngeal irritation is often relieved, at least for a short time, 
by small doses of morphine, it is yet safe to maintain that such 
treatment is unsatisfactory. Goodno offers some excellent ad- 



254 SPECIFIC INFECTIOUS DISEASES. 

vice concerning the management of the cough, calling attention 
to the necessity of carefully studying each case for the purpose 
of removing whatever may irritate the respiratory organs and 
provoke unnecessary' coughing, for it must be remembered that 
a certain amount of coughing is necessary to get rid of accumu- 
lated secretions. Good ventilation of rooms, restful, quiet and 
good cheer before retiring, proper assistance in undressing, due 
preparation of the bed, not forgetting soft flannel sheets, care 
to keep the room of the patient free from tobacco smoke and 
from unpleasant, irritating odors, — all these must be looked 
after, and will often prevent unnecessary coughing. The wise 
use of stimulants and close attention to diet and digestion are 
also helpful. Catarrh of the larynx, pharynx, naso-pharynx, 
ulcerations in the throat, in fact, any abnormal condition of the 
respiratory organs which can be reached, must receive prompt 
treatment. The remedies oftenest of service are: Phosphorus, 
Bryonia, Calcarea, Lycopodium, Stannum, Sulphur, Kali 
carbonicum, belladonna, hyoscyamus, iodine, ipecacu- 
ANHA, Antimonium tartaricum, Sanguinaria, Arsenicum, 
Lobelia, Lachesis. 

The pains in the chest are usually pleuritic, often myalgic. 
If the former, perfect rest and the use of Aconite, Bryonia, 
Ranunculus, Kali carbonicum, with the application of heat 
and mild counter-irritation (mustard-draft), are usually suffi- 
cient. If myalgic, a bandage firmly applied to the chest is 
frequently very helpful, with Aconite, Cimicifuga, Bryonia, 
and remedies of that class, supported by a generous diet. 
Goodno recommends Nitrate of Aconitine, 3x, repeated every 
hour. 

Fever, if moderate, requires no special treatment. It is 
usually much relieved by having a change of climate. The 
writer knows of cases who for weeks had a continuously 
elevated temperature and arrived on the coast with the fever 
almost wholly and permanently broken. Perfect rest must be 
enforced when the temperature runs high. The remedies which 
promise most are: Baptisia, Ferrum phosphoricum, Arseni- 
cum, Arsenicum chinin., Aconite. The "tar-products," espe- 
cially phetmcetin and acetanilid,in three-grain doses, and more, 
are very commonly used, but possess slight, if any, permanent 
value. 



TUBERCULOSIS. 255 

Night-sweats constitute one of the most perplexing special 
symptoms of phthisis. The remedies homoeopathically indi- 
cated are: Arsenicum, China, Sambucus, Pilocarpine, Iodum, 
and the mineral acids. — Agaricin (agaric acid), in doses from 
y%toV^ grain, two or three times daily, has been highly recom- 
mended. — Atropine sulphate (in a solution of one-half grain 
to half an ounce of water, three to seven drops at bedtime) is a 
standard prescription; it must be given cautiously, at no time 
exceeding ten drops of the solution atone dose. If ten drops at 
a dose has proved inefficient, after several successive nights, the 
dose must be divided, giving five drops about two hours before 
retiring, the balance when going to bed. After a week's time 
the dose must be reduced, by one drop each night, and omitted 
as soon as possible. — Homatropine (Vi grain by injection), 
Picrotoxin (gr. gV a t bedtime), Camphoric acid (g 1 ^ grain at 
night-fall, in a capsule), and Strychnine (a full dose at night), 
have each their warm advocates. Sponging in a solution of 
two drachms of chloral hydrate in about two gobletfuls of 
brandy and water, in equal parts, is recommended by Nicolai 
and has been of service in a number of unmanageable cases. 
Sponging in dilute vinegar is often helpful. 

Haemorrhage demands the exhibition of Ipecacuanha, Ham- 
amelis, Aconite, Millefolium, Secale, Ledum, Ferrum 
aceticum. Though invariably alarming to the patient and 
friends, it is not often fatal, and by relieving the congestion 
may actually be helpful. If slight, it may be safely ignored. 
The patient must be kept quiet physically and mentally, must 
not be allowed to talk, and should be kept in a position to favor 
the ready outflow of blood. Bits of ice in the mouth and an 
ice-bag over the heart are often useful. Table-salt in large 
doses is a domestic remedy of service in an emergency. Ergo- 
tine, hypodermically, or ergot by the mouth in ten to sixty 
minims of the fluid extract, every half-hour, then at longer 
intervals, is often useful by its physiological action. Oil of 
erigeron, oil of turpentine (5 to 20 minims on sugar every half- 
hour to hour), eucalyptol, aromatic sulphuric ether, extract of 
hamamelis, and others, may be added to this list. 

Diarrhoea is usually controlled by Arsenicum, Sulphur, 
Mercurius, China, Pulsatilla, Nux vomica, Argentum 
nitricum. Injections of linseed-tea, to which may be added 



256 SPECIFIC INFECTIOUS DISEASES. 

from 30 to 40 minims of deodorized opium, are serviceable 
when there is ulceration of the large intestine. Indigestion 
commonly demands Nux vomica, Pulsatilla, Carbo vegeta- 
bilis, Argentum nitricum, Kreosotum, Lycopodium, Arseni- 
cum, Ferrum, and the moderate use of stimulants with the 
meals. If vomiting- is marked, the throat may require special 
attention. Astringents, locally applied, often act nicely. If 
vomiting occurs every morning, a copious drink of hot water 
or hot milk, as soon as the patient wakens and before he raises 
his head from the pillow, is excellent. Mustard drafts over the 
epigastric region and ice to the nape of the neck are recom- 
mended. 

CBdema of the legs requires, in addition to Arsenicum, Apis, 
and other indicated remedies, careful bandaging and rubbing of 
the limbs, which should be kept elevated. Ointments contain- 
ing carbolic acid or starch poultices are useful when itching is 
troublesome. Bed-sores are not infrequent in tedious cases, 
and have been most successfully treated by dusting with iodo- 
form, zinc oxide, subnitrate of bismuth, tannin, or, better, with 
iodoform collodion. Insomnia may be relieved by removing 
the cause through the agency of appropriate treatment; spong- 
ing, general or along the spine, hot foot-baths, a mild mustard 
draft to the epigastrium, occasionally cold water to the head, 
are also helpful. 

The following remedies are useful in the constitutional treat- 
ment of phthisis: 

Sulphur, from the 6th to the 12th, and higher, when the 
patient complains constantly of being intolerably hot, with in- 
clination to keep the feet outside the bedclothes; there is sore- 
ness in the upper chest; chronic, dry, hacking cough, with, oc- 
casionally, free discharge of purulent matter. Characteristic 
expressions of the scrofulous taint. Morning diarrhoea. Lack 
of appetite, but faintness if his meals are not served regularly. 
Tendency to venous plethora and haemorrhoids. Sulphur is 
of much greater value in the treatment of consumption than is 
usually recognized; it often does brilliant work, especially after 
pneumonia which does not resolve. — Arsenicum is frequently 
indicated. Clapp has found it "one of the most \-aluable reme- 
dies for the tubercular cachexia." Its cough is accompanied 
with great dyspnoea, especially when King down, which 



TUBERCULOSIS. 257 

obliges the patient to sit in an upright position; it is dry or 
has expectoration of frothy, glairy, stringy mucus, which later 
may become heavy, greenish, fetid. It is of particular value in 
the later stage, when the fever is almost continuous, burning 
dry, with great emaciation; haggard, drawn, grayish-white, 
waxy face; constant thirst; quick, light pulse; great depression 
of spirits; intolerable nervous tension. This nervous tension, 
often one of the most distressing symptoms, frequently yields 
under the persistent exhibition of Arsenic, and I have derived 
benefit from Hempel's advice to use in such states three-drop 
doses of Fowler's solution of Arsenic when the trituration 
fails. It often is of great service in the relief of gastric symp- 
toms and of colliquative diarrhoea. — Arsenicum iodatum may 
be advantageously substituted if laryngeal complications are 
added to the ARSENic-indications. — Ferrum metallicum is of 
service in the cough of persons of marked tuberculous predis- 
position, with soreness, fullness, and aching all over the chest; 
flying, stitching pains; dry, teasing cough; slight exertion 
causes a sense of great fatigue in the chest, flushing in the face, 
nosebleed, moderate haemoptysis. Dyspnoea, relieved from 
warmth; fulness and pressure in the pit of the stomach. Pain- 
less, watery diarrhoea. Watery menses. Amenorrhoea. Fer- 
rum phosphoricum is often substituted. — Calcarea carbon- 
ica is particularly adapted to young people and women who pos- 
sess peculiarities of temperament which belong to this remedy. 
It does brilliant work in the early stage, when the "drift" of 
the case is well pronounced, and there is a tendency to copious 
and too frequent menstruation in large women with full bust, 
lax fibre, glandular enlargements, and cold, wet feet. Digestion 
is deranged. There is a constant sense of great fatigue. 
Dyspnoea is easily provoked by exertion, especially by going 
upstairs. Cough may not be severe, or there may be coughing 
in the early part of the day, with copious, yellow, at times of- 
fensive, expectoration. When indicated, it acts promptly, and 
its effects are permanent. — Iodum. In the first stage, in young 
persons who are scrawny and bear the marks of scrofulous 
diathesis, as glandular swellings, deranged digestion, with vo- 
racious hunger and progressive emaciation. The cough is in- 
duced by tickling in the larynx and under the sternum; there is 
expectoration of stringy, transparent mucus, sometimes streak- 
17 



258 SPECIFIC INFECTIOUS DISEASES. 

ed with blood. A solution of five drops of the tincture to the 
ounce of water, inhaled, is often serviceable when the larynx is 
involved. — Kali carboxicum. Stitching pains in different parts 
of the body, chest, teeth, etc. Cough severest in the early 
morning, at 3 A. M., with constrictive pain in the chest and 
throat, redness of the face, and sweat all over. Sense of hol- 
lo wness in the chest, worse from talking. ''Goneness" at the 
stomach, with belching of foul gas, better from eating. Expec- 
toration of firm round masses, like a pea, flying from the 
mouth when coughing; copious, purulent expectoration. It is 
"beneficial both in incipient and later stages, especially for 
women run down after confinement or over-lactation." — Phos- 
phorus should be one of our most valuable remedies, judging 
from its symptomatology. H. C. Clapp calls it the "king of 
remedies for phthisis" and states that he has seen more recov- 
eries under its exhibition than under the use of any other 
single remedy. I have been less fortunate with it. It is 
an important remedy when the patient suffers from con- 
stant, dry, hacking cough, with pain and soreness in the chest 
and burning soreness in the larynx, much worse from coughing. 
There is hoarseness, especially in the evening. Dyspnoea. Ach- 
ing in, and between, the shoulders; inability to lie on the affected 
side, and aggravation of cough from doing so. As the case 
progresses, the adaptibility of Phosphorus to phthisis becomes 
more and more striking. There is great exhaustion, emacia- 
tion, hectic, loss of appetite, painless diarrhoea, night-sweats, 
with expectoration varying in quantity and quality, rust- 
colored, bloody sputum being especially- prominent. It acts 
best in tall, slender persons of light complexion, especially in 
young women. — Staxxum is well suited to those cases in which 
"weakness of the chest" is a conspicuous SA-mptom. The chest 
is so weak that the patient cannot say more than a few words at 
a time; he must stop and rest to get his breath. His legs, also, 
are weak, and there is a great deal of general prostration. The 
cough is loose and rattling, the expectoration at first mucoid, 
later green and sweetish. There is pressure and bloating at 
the stomach after eating; chilliness alternating with flashes of 
heat; profuse night sweats. Staxxum should not be given too 
low. Even in the third trituration it often appears to check the 
cough and simultaneously cause a general aggravation of symp- 



TUBERCULOSIS. 259 

toms. — Lycopodium is adapted to old people who have long 
suffered from pulmonary trouble. The indications furnished by 
Lilienthal are reliable; abundant, purulent expectoration, cough 
day and night, with bloody mucus or purulent, lemon-yellow, 
green or white sputa; hectic fever; rattling breathing, with 
dropped jaw and stupor from weakness and exhaustion after 
coughing; cold, clammy, sour, fetid perspiration; intercurrent 
pleuritic attacks, continual stitches on the left side with sensa- 
tion of constriction in the chest. There is usually present the 
atonic dyspepsia, with much intestinal fiatulenc}^ "goneness" 
at the stomach, bloating and sense of distension in the abdo- 
men, sallow, jaundiced complexion, and tardiness and slowness 
of the stool. 

In addition to these remedies, consult Antimonium tartari- 
cum, Bryonia, Ipecacuanha, Lachesis, Rumex, Sanguinaria, 
Spongia, Belladonna, Hyoscyamus, Drosera, Hepar sul- 
phur., and Silica. 

The liberal use of hypo-phosphites and, when tolerated, of 
cod liver oil, maintained for a long time, is beyond doubt 
beneficial. 

LARYNGEAL TUBERCULOSIS. 

Tuberculosis of the larynx rarely occurs, but it may occur, as 
a primary affection. Usually it is secondary to pulmonary 
tuberculosis, from eighteen to thirty per cent, of the latter pre- 
senting laryngeal complications. In such cases the pulmonary 
symptoms are not always strongly pronounced; occasionally 
cases of extensive laryngeal involvement are seen when there is 
but slight tuberculous invasion at one apex. It affects men 
oftener than -women. 

Morbid Anatomy. — A laryngeal catarrh, with tubercles scat- 
tered through the mucous membrane, more abundant near the 
blood-vessels. By fusion larger tuberculous masses are formed 
which undergo caseation and ulceration, constituting flat 
irregular ulcers, sometimes deep and funnel-shaped, covered 
with grayish or yellowish exudation, and surrounded by thick- 
ened mucous membrane. The disease may extend in every 
direction, involving the cricoid cartilage, pharynx, and even 
fauces and tonsils. The involvement of the mucous and sub- 
mucous tissues is general and marked, often accompanied with 



260 SPECIFIC INFECTIOUS DISEASES. 

much oedema; infiltration of the muscular tissue promptly 
occasions vocal defects. The inter-arytenoid region and the 
epiglottis are most frequently the seat of active structural 
changes, resulting in great enlargement, distortion, and more 
or less destruction of the parts, especially of the epiglottis. 
Extensive ulceration more frequently takes place when the upper 
surface of the epiglottis is involved, and perichondritis and ex- 
foliation of the cartilages may result. Stenosis of the larynx 
has been noted in comparatively rare cases. 

The characteristic features observed with the laryngoscope 
are pallor and infiltration of the mucous membrane, infiltra- 
tion of the vocal cords, and shallow, broad, grayish ulcers 
whose surface, according to Fraenkel, resembles sliced bacon. 

Symptoms. — The symptoms resemble those of pulmonary 
phthisis, with certain additional, easily recognized peculiarities. 
Of these, one of the most striking is an early change in the 
quality of the voice, which at first becomes husk}-, then hoarse, 
and in the advanced stage often is entirely lost. The import- 
ance of this symptom, in connection with pulmonary tuber- 
culosis, is sufficient to always arouse serious apprehension. 
The cough, at first lar3 r ngeal or simph' that of the pulmonarA^ 
affection, becomes hoarse and ineffective as the disease ad- 
vances, accompanied with expectoration of purulent, possibly 
blood-streaked, matter, in some cases containing elastic tissue. 
There is frequently severe pain upon coughing, which radiates 
into the ears and grows in intensity as the disease progresses. 
Dysphagia is marked and distressing; it is nearly always pres- 
ent in the advanced stage, and grows worse as ulceration of 
the pharynx and epiglottis becomes more extensive. When the 
epiglottis is partly destro3 r ed, every attempt to swallow brings 
on a violent parox3 T sm of coughing and strangling, which is 
intensely painful and exhausting, and greatly interferes with 
eating. 

The diagnosis usually, is not difficult; in perplexing cases it 
may be solved by bacteriological examination. The prognosis 
is invariably grave, though somewhat more hopeful under 
modern methods of directly treating the throat. 

Treatment — The general management of the case does not 
differ from that of pulmonar}- phthisis. The necessit}^ of pay- 
ing close attention to the throat is apparent. Cleanliness is of 



TUBERCULOSIS. 261 

great importance, and can be secured by spraying the parts 
with some alkaline solution, as boracic acid or chloride of 
sodium (10 grs. to the ounce of water), or Listerine diluted in 
two or three parts of water. This may be followed by a spray 
of menthol or eucalyptol in warmed vaseline. In indolent cases 
spraying with peroxide of hydrogen is useful. In more ad- 
vanced cases sprays of a solution of iodine in alcohol are highly 
recommended, and not infrequently the direct application of a 
strong, even saturated, solution of iodine has been advanta- 
geously employed. I have found the inhalation of a weak solu- 
tion of iodine, ten drops to the ounce of water, and even 
weaker when the throat was very irritable, by steam atomizer, 
persistently followed, of genuine benefit. Kramer's lactic acid 
treatment, consisting of the application of a 20 per cent, wa- 
tery solution of the acid, gradually increased in strength, has 
proved satisfactory. If there is much pain, the insufflation, 
two or three times daily, of iodoform and morphia, the parts 
having been thoroughly cleansed, affords much comfort. Vari- 
ous other agents have been used, as solutions of tannic acid, 
nitrate of silver, or sulphide of zinc; the aniline dyes, especially 
pyoktanin, as spray in saturated solution or applied directly 
by cotton on forceps, has been urged; kreosote has its warm 
advocates. Peterson advises Calendula tincture, in solution of 
1 to 20, with the addition of two or three drops of carbolic 
acid to the ounce. 

Feeding may become difficult from the pain experienced upon 
swallowing. Spraying with a 4 per cent, solution of cocaine 
will give at least temporary relief. It is well to thicken all 
fluids taken, and to follow the method of Wolfenden, who di- 
rects the patient to hang his head over the side of the bed and 
suck the fluid used through rubber-tubing from a glass or 
deep dish placed on the floor. 

Excision of the diseased tissue has been practiced by Heryng. 

Therapeutics. — Iodine has proved one of the most efficacious 
remedies. Its great value in scrofulous and tuberculous con- 
ditions is generally recognized, and T. F. Allen's note that "it 
is particularly important to observe that it controls inflamma- 
tion (with high temperature) of many, if not all, parenchyma- 
tous structures, particularly the lungs, when the indications 
permit its exhibition," is made good by experience. It is indi- 



262 SPECIFIC INFECTIOUS DISEASES. 

cated when there is violent hoarse, croupy cough, with tight- 
ness and soreness in the larynx, referable to one spot, ulcera- 
tion, and muco-purulent or bloody expectoration. "When the 
ary-epiglottic and inter-arytenoid folds are thickened, the re- 
sult of proliferation of connective-tissue elements." (Ivins.) 

Mayerhoffer maintains that the iodides, as a class, exert a 
positive curative influence. He says: "The iodides of kali, 
natrium, and calcium, are of use chiefly as modifiers of the con- 
stitution and the diathesis. The preparations used are, 
usually, lx five drops twice a day for two consecutive days, 
followed by a week's rest. Their influence is, however, not less 
marked on the lining of the larynx; the ulcer assumes a better 
aspect and shows a tendency to cicatrize. The iodides of mer- 
cury are of great service when there is much congestion, swell- 
ing and redness in any part of the laryngeal lining; healing 
ulceration. I commend to your attention the Arsenicum 
iodatum, 3x trit., in cases of deficient nutrition, when, not- 
withstanding a good appetite, the patient loses weight. The 
Iodide of baryta is to be preferred in enlargement of the tonsils 
and general indolent swelling of the glands of the neck. The 
Aurum iodatum, 3x trit., I have found very useful in torpid 
ulcerations of the larynx, which resisted all other remedies, 
whether topical or internal. From the moment this agent came 
into action, there appeared almost immediately great vascular 
activity in the diseased parts, and the torpid ulcers made great 
strides toward healing. In one case which resisted for months 
the other iodine preparations, the cicatrization of the ulcers 
on the arytenoid lining was brought about in three weeks. In 
none of the cases where the Iodide of gold did good service 
could I trace any syphilitic taint." (Ivins: Diseases of the Nose 
and Throat.) 

My own experience has demonstrated the particular useful- 
ness of the Iodide of arsenic . Next in importance stands Nitric 
acid, when there is violent, dry, spasmodic, choking, exhaust- 
ing cough, with sharp, stitching, knife-like pains in the (left 
side of) larynx. — Phosphorus is indicated by laryngeal raw- 
ness and soreness from speaking, coughing, and from press- 
ure upon the larynx, wheezing inspiration, aphonia, etc. — 
Seleniate of soda was highly recommended by Mayerhoffer 
in cases where the expectoration consists of small lumps of 



TUBERCULOSIS. 263 

bloody mucus, and where there is hoarseness. J. S. Mitchell 
has confirmed its value in the early stage of the disease. 

All remedies should be consulted which have a specific action 
upon the larynx, especially Ferrum phosphoricum, Drosera, 
Argentum nitricum, Merc, nitric, Kali bichromicum, San- 
guinaria. 

TUBERCULOSIS OF THE SEROUS MEMBRANES. 

This usually is the result of direct extension from contiguous 
structures or is secondary in character. Cases do, however, 
occur in which the serous sacs appear to be the exclusive seat 
of tuberculous deposits. 

Tuberculosis of the pleura is primary or secondary. The 
former is rare, especially as an acute manifestation; the exuda- 
tions are of a sero-fibrinous or of a haemorrhagic character. In 
the chronic form miliary granulations are found in the infil- 
trated connective tissue which separates the thickened and 
degenerated layers of the sac. The secondary form is quite 
common. The visceral layer of the pleura is invariably in- 
volved in pulmonary tuberculosis and there are found chronic 
inflammation, extensive adhesions, and tuberculous masses 
scattered throughout. Again, direct extension of the tubercu- 
lous process is not infrequent. Perforation of the pleural sac, 
at a spot where softening of the structure has taken place, re- 
sulting in pyo-pneumothorax, often takes place. The exuda- 
tion may be sero-fibrinous, haemorrhagic, or purulent. 

The pericardium is less often the seat of tuberculous disease, 
and its recognition is attended with difficulty. In the majority 
of cases tuberculosis of the pericardium depends upon the ex- 
istence of foci in the lungs or pleura, or it arises from invasion 
of tubercles through the mediastinal lymph-glands. Undoubt- 
edly some cases of purulent pericarditis are tuberculous in 
character, though this fact can only be demonstrated by the 
existence of foci of tuberculous action elsewhere. The peri- 
cardium may also suffer as the result of general tuberculous 
infection or it may become involved by extension of the disease 
from other organs or structures, as the sternum, spine, or lungs. 
Tuberculosis of the peritonaeum is quite common. It occurs at 
all ages, especially between twenty and forty. In children it is 
frequent, and closely connected with mesenteric and intestinal 



264 SPECIFIC INFECTIOUS DISEASES. 

affections. It generally is a part of miliary and of chronic pul- 
monar}^ tuberculosis. It is almost always milian-in character, 
small gray granulations freely studding the peritoneal surface 
and in close relation to the lymphatic vessels. Careful exami- 
nation of the omentum is often necessary to establish the 
identity of the process. It may be primary- and local. Osier 
recognizes the following forms: Acute miliary tuberculosis, with 
sero-hbrinous or bloody exudation. Chronic tuberculosis, 
characterized by larger growths which tend to caseate and 
ulcerate. It may lead to perforation of the intestinal coils. 
The exudate is purulent or sero-purulent, and often is sacculated. 
Chronic fibroid tuberculosis, which may be subacute from the 
onset, or which may represent the first stage of an acute 
miliary eruption. The tubercles are hard and pigmented. 
There is little or no exudation, and the serous surfaces are 
matted together by adhesions. The symptoms are of a com- 
plex character. Sometimes, especially in the latent form, they 
are so vague as to escape recognition. If, on the other hand, 
the disease is of a very acute form, there are symptoms of 
enteritis, peritonitis, and even acute hernia, with excessive 
pain, abdominal tenderness, tympanitis due to inflammatory 
infiltration, and a temperature reaching 103° and 104°. When 
the onset is very slow, the low continuous fever, the abdominal 
tenderness, and the tympanitis give it a close resemblance to 
typhoid fever. In the chronic form the temperature may be 
quite low, even subnormal; tympanitis is present when there 
are extensive adhesions. Ascites, usually moderate, sometimes 
hemorrhagic, is frequent. "It may simulate the effusion in 
cirrhosis of the liver, of which disease it is to be noted that 
tuberculous peritonitis is often a final complication." 

A striking feature is the frequenc}" with which tumors in the 
peritoneal cavity are observed. These are due to: a) pucker- 
ing and rolling up of the omentum, usually seen in the umbili- 
cal, less often in the right iliac, region; b) sacculated exudations, 
more often found in the middle abdominal zone, flanks, or 
pelvis; c) thickening and retraction of the intestinal coils which 
may possibly involve the entire intestine; d) enlargement of the 
mesenteric glands. The diagnosis of these tumors is difficult; it 
depends chiefly upon the recognition of tubercular disease in 
some part of the bod\\ 



TUBERCULOSIS. 265 



TUBERCULOSIS OF THE ALIMENTARY CANAL 

The lips are very rarely involved; if affected, the ulcer is 
readily mistaken for a chancre or an epithelioma. Tuberculous 
affection of the tongue is also rare. It appears as a small 
nodular prominence on the dorsum or edges, forming an uneven 
ulcer with rough, fatty base, resembling epithelioma and syph- 
ilitic ulcer. From the latter it is distinguished by the absence 
of glandular enlargement at the angle of the jaw and failure to 
improve under the persistent use of Iodide of potassium. The 
hard and soft palate and the tonsils are rarely involved. The 
pharynx may become implicated by extension of tuberculous 
laryngitis; its most striking symptom is the excessive pain 
caused by swallowing. The oesophagus is almost exempt, save 
the inconsiderable extension which is occasionally noted during 
laryngeal phthisis. The same applies to the stomach; only a 
few authenticated cases of tuberculosis of the stomach have 
been recorded; in some of these perforation by a tuberculous 
gland had taken place. 

Intestinal tuberculosis is much more frequent. It may be 
primary, in the mucous membrane, and is then oftenest seen in 
cljjldren in connection with peritonitis or disease of the mesen- 
teric glands. In adults it is comparatively rare. It is marked 
by symptoms of intestinal catarrh, fever, and colicky pain. If 
beginning in the caecal region, there are symptoms of typhlitis, 
which may gradually subside, to recur in a few weeks. Per- 
foration into the peritonaeum, or the formation of a pericecal 
abscess, with perforation, may occur, in exceptional cases fol- 
lowed by partial healing and stricture of the bowel. Secondary 
involvement is, however, far more frequent. It occurs chiefly 
in connection with pulmonary phthisis, and by preference in- 
volves the ileum, caecum, and colon. The mucous membrane 
and the solitary and agminated glands are first affected. The 
submucous and deep structures become involved in the ulcera- 
tive process, giving rise to perforation, peritonitis, and stricture 
of the bowel from cicatrization. The intestinal tuberculous 
ulcer is irregular and usually "girdles" the gut; its edges and 
base are infiltrated, often caseous; it dips deep into the intes- 
tinal structures, shows tuberculous inflammation of the neigh- 



266 SPECIFIC INFECTIOUS DISEASES. 

boring lymph vessels, and abounds in colonies of 3'oung tuber- 
cles in the serosa. 

The rectum is frequently the seat of tuberculous disease in 
connection with fistula in ano in persons suffering from pul- 
monary phthisis. In these cases an operation is generally con- 
sidered inadvisable; if the knife is used at all, free excision 
should be practiced. 

At times intestinal tuberculosis is the result of extension of 
tuberculosis of the peritonaeum, in which case extensive inflam- 
matory adhesions may be formed, numerous foci of tuberculous 
inflammation may be scattered throughout the intestine, and 
perforation of the bowel may take place. 

TUBERCULOSIS OF THE LIVER. 

Of slight clinical importance, and rarely accompanied by 
local symptoms. It is a common feature of general tubercu- 
losis, in which case the liver appears pale and fatty; the miliary 
granulations are so small as to be almost imperceptible. In 
some cases the finer bile-vessels are the seat of the invasion; it 
so, they resemble small abscesses, with soft center and bile- 
stained contents, and often are very numerous. Again, the 
liver is the seat of large masses of cheesy substance, varying in 
size from that of a hazelnut to an orange, or larger. Or a tme 
tuberculous cirrhosis ma}' exist, especially when there is tuber- 
culous disease of the peritonaeum and a peri-hepatitis, of which 
a sclerosis of the portal canals may be a feature. Ascites may 
be present. 

TUBERCULOSIS OE THE GENITO-URINARV 
SYSTEM. 

Tuberculosis of the kidney, as a primary disease, is not very 
rare. Usually, however, renal tuberculosis is secondary to a 
local manifestation of a general tuberculous invasion. It may 
occur at any age, but is more common during middle life, and 
is seen oftener in men than in women. The disease first attacks 
the pyramids and the calyces; necrotic changes and caseation 
take place; all the pyramids are rapidly invaded by colonies of 
tubercles, which soon extend to the mucous membrane of the 
pelvis. By extension downward, the ureters, sometimes the 
bladder, and in rare cases the prostate gland, become involved. 



TUBERCULOSIS. 267 

Both kidneys may be affected. As a general thing, one only 
is involved, presenting a series of cysts or cavities, filled with 
caseous matter in which lime salts may be deposited; or there 
may be thickening of the pelvic walls, with caseous nodules 
scattered throughout the organ, accompanied with necrotic 
changes and thickened and adherent capsule. The other kidney 
may remain normal; but more frequently it is superficially 
necrotic. The ureters commonly are thickened, there is ulcera- 
tion and caseation of the mucous membrane, and possibly ex- 
tension of the disease, in males, into the bladder, prostate, 
seminal vesicles, and testicles. 

The symptoms are those of pyelitis so long as extension to 
the bladder has not taken place, and of very moderate severity 
for a considerable period of time; when advanced, loss of 
strength and flesh, emaciation, chills and irregular fever, and 
tenderness to pressure in the region Of the kidneys are observed. 
In exceptional cases great distension of the pelvis exists. The 
urine contains albumin, pus cells, epithelium, tubercle bacilli, 
and at times flocks of caseous matter and blood. Extension 
into the bladder causes symptoms of cystitis. Spontaneous re- 
covery has taken place; perforation of the cyst, with subse- 
quent peritonitis, is a possible complication. 

The bladder is rarely tuberculous, save as this results from 
tuberculous disease of the kidneys or other parts; the same 
applies to the ureters. Small ulcers, usually confined to the 
mucous coat, coalesce and form the large irregular tuberculous 
ulcer. The symptoms are those of vesical catarrh with fre- 
quent voiding of offensive, ammoniacal, purulent urine of, 
usually, normal specific gravity, containing albumin, pus, ba- 
cilli, epithelial cells, and other debris. 

The prostate gland and seminal vesicles axe often affected dur- 
ing tuberculous inflammation of the kidneys. Tuberculosis of the 
testes is not a rare disease. It may be primary or secondary, 
more often the latter. It is often seen in young children, even 
in the foetus, the tubercles here usually first affecting the tunica 
albuginea. It is an expression of general tuberculosis, and is 
always serious. In adults the substance of the testicles is first 
invaded. Caseation does not always result. An operation 
has been frequently followed by general infection. 

The Fallopian tubes may be the seat of primary tubercu- 



268 SPECIFIC INFECTIOUS DISEASES. 

losis, usually bilateral, with enlargement, thickening, and 
infiltration of the tubes, caseation of their contents, ex- 
ternal adhesions, and possibly extension to the uterus. 
Tuberculous salpingitis has been seen in young children; 
it may give rise to serious local disease, and may re- 
sult in peritonitis. The uterus is rarely affected. Thickening 
and caseation of the mucous membrane of the fundus, and the 
appearance of nodules in the muscular wall mark the presence 
of the disease. Extension into the vagina is possible. 

TUBERCULOSIS OF THE NERVOUS SYSTEM. 

Acute miliary tuberculosis, involving the meninges and caus- 
ing effusion, is the most important. Less frequent is a tuber- 
culous meningo-encephalitis which generally^ is localized, occurs 
more commonly during the course of a pulmonary phthisis, 
and by the irritation due to the presence of the tubercle nodules 
sets up a train of very serious symptoms which differ widely, 
according to the size and location of the tumor. The so-called 
solitary tubercle is still less frequent; it consists of a tubercu- 
lous mass, greatly varying in size, at times as large as an 
orange, occasionally multiple, which gives rise to such symptoms 
as follow the presence of any other cerebral tumor. The last 
two forms are chronic, are found chiefly among young subjects, 
and usually occur in connection with tuberculous processes in 
other organs, especially the lungs. 

The tubercle, on section, presents a cheesy appearance, is 
usually of considerable hardness throughout, save in the center 
where it may be quite soft, and is encircled by soft, translu- 
cent tissue; calcification ma}' occur. Thickening of the pia 
mater, the formation of adhesions, interference with the circu- 
lation and resulting softening of the brain substance, pressure 
upon the nerve centers, and other disastrous results, are un- 
avoidable. The same forms are found in the spine, producing 
symptoms of spinal meningitis or spinal tumor. 

TUBERCULOSIS OF THE BLOOD VESSELS. 

The existence of primary- infection is doubtful. Osier states 
that tuberculosis may occur in a large artery and not result 
from external invasion. In the course of tuberculous disease of 
any organ, as the lungs, the walls of the vessels may become 



SYPHILIS. 269 

infected, undergoing all the changes peculiar to the tuberculous 
process, the resulting softening of tissue frequently leading to 
haemorrhage. Or, acute infiltration of the arteries may take 
place in tuberculous organs and cause thrombosis. 

The blood-vessels, especially the veins, frequently become 
carriers and distributors of the infection, and thus play an im- 
portant part in the history of tuberculosis. 



SYPHILIS. 

A specific disease, confined to the human race, chronic in 
character, propagated by inoculation over an abrasion of the 
skin or mucous membrane and by hereditary transmission. It 
has a long period of incubation, and clinically presents three 
stages of development: a) a primary sore at the point of incu- 
bation, with subsequent glandular enlargement; b) constitu- 
tional symptoms, with affections of the skin and mucous mem- 
brane; c) specific disease of the skin, bones, muscles and viscera. 

./Etiology. — A micro-organism, described by Lustgarten, is 
probably the active element in the infection. It resembles the 
tubercle bacillus, but is somewhat enlarged at the ends. It is 
present in all syphilitic lesions and has only recently been dis- 
tinguished from the smegma bacillus. 

Infection may take place in various ways. In an overwhelm- 
ing majority of cases it occurs during sexual intercourse with a 
syphilitic; not infrequently it is accidental, as, for instance, in 
surgical or obstetrical practice, the surgeon or obstetrician 
being inoculated through contact with a syphilitic patient or, 
if himself infected, conveying the disease to the patient by direct 
contact or through infected surgical, obstetrical, or dental in- 
struments. Infection at the nipple from suckling a syphilitic 
child or, rarely, on the lips from the kiss of a syphilitic, or 
through the agency of humanized vaccine lymph (a mode of 
infection still called into question by many competent observ- 
ers) are also examples of accidental syphilitic infection. Syph- 
ilitic ulcers about the mouth are commonly the result of vicious 
practices. Hereditary transmission, i. e. transmission of 
syphilis from parent to child, is frequent. If both parents are 



270 SPECIFIC INFECTIOUS DISEASES. 

sjrphilitic, one having infected the other prior to conception, 
the offspring of such intercourse cannot be expected to escape. 
If the father is syphilitic, but the mother healthy, the danger of 
transmission is great in the early stage of the disease, but the 
child may escape; each successive year materially lessens the 
danger of begetting a syphilitic child, so that the child of a 
father in the tertiary stage of syphilis is in little, if any, danger. 
The tenacity of the virus is, however, well shown in the com- 
parative frequency with which a syphilitic child is born to a 
father who, at one time syphilitic, had apparently made a per- 
fect recovery under appropriate treatment. A woman who has 
acquired syphilis is very likely to bear syphilitic children, even 
though the father be healthy. On the other hand, a healthy 
woman bearing a syphilitic child becomes herself immune, and 
cannot be infected; the child may infect the most healthy nurse, 
"yet it is never known to infect its own mother, even though 
she suckle it while it has venereal ulcers on the lips and 
tongue." (Colles's law.) If the mother become syphilitic dur- 
ing pregnancy, the child may, or may not, be syphilitic. 

Whatever unduly taxes or weakens the system may be con- 
sidered a predisposing cause. Hence ill health, unfavorable 
climatic conditions, the relative weakness of immature youth 
and of old age, alcoholic and other excesses, intercurrent at- 
tacks of severe illness, and all other depressing influences, by 
lessening the powers of resistance, certainly give to the infec- 
tion a degree of virulency which it otherwise would not pos- 
sess. A natural susceptibility to the action of the syphilitic 
poison appears to exist in some cases; not infrequently per- 
sons who are in the possession of splendid health and most 
favorably situated, will manifest symptoms of intense activity 
on part of the specific poison which cannot be explained upon 
other grounds. 

The essential anatomical features of syphilis is cell prolifera- 
tion. 

ACQUIRED SYPHILIS. 

For purposes of study a division into the three usually recog- 
nized stages is practical; yet, in actual practice these stages not 
only often blend into each other, but the order of their occur- 
rence may be greatly changed; the secondary eruption, for in- 



SYPHILIS. 271 

stance, may appear before the primary sore has cicatrized. 
The difference in the course of the affection, and its preference 
in individual cases for certain organs and structures, un- 
doubtedly depends upon individual peculiarities which it is not 
often possible to recognize. 

The primary stage begins with the appearance of the initial 
sore, and continues until the development of constitutional 
symptoms, covering a period of from five to twelve weeks. 
The initial sore (initial sclerosis, hard chancre, Hunterian 
chancre) is situated at the point of inoculation on the abraded 
skin or mucous membrane; hence, it is almost always seen on 
the genitalia. It is small, of dark-reddish color, and in itself 
causes slight annoyance except when irritated by chafing from 
clothing or other causes. It presents a hard, indurated base, 
due to cell infiltration, and is frequently coated with a glairy, 
thin, viscid secretion which gives to it a glazed aspect. It grad- 
ually increases in size, breaks in the centre, and leaves a small 
ulcer. The indurated character of the sore is of the greatest 
diagnostic value. The induration is easily detected by manip- 
ulation when the sore is situated on the prepuce, scrotum, 
labia, or lips; for evident reasons it is much less readily deter- 
mined when the sore is on the glans penis or on the vaginal 
portion of the uterine cervix; in these situations it also is less 
papular and more frequently resembles a flat, slightly elevated 
ulcer. If inoculation results from vicious practices, the initial 
sore is probably about the mouth, anus or rectum; if acciden- 
tal, on the fingers or hands. Exceptionally the primary sore 
may be wholly overlooked, as when it is situated within the 
urethra. It disappears within a few weeks, sometimes not for 
six or eight weeks. Excision of the sore does not affect the 
course of the disease. 

The virus finding its way to the lymphatic glands, lymphatic 
adenitis, involving the lymph glands -which anatomically are 
closest related to the seat of the primary sore, takes place, from 
the eighth to the fourteenth day after the appearance of the 
sore, and continues for, usually, six or seven weeks. The ex- 
tent of this glandular enlargement depends somewhat upon 
the extent of the chancre and upon the number of glands with 
which the lymphatics closely related to the primary sore com- 
municate. The enlargement is usually painless, rather tedious, 



272 SPECIFIC INFECTIOUS DISEASES. 

may involve the periglandular tissue, and on rare occasions 
may terminate in suppuration. 

There is no impairment of the general health. 

Secondary syphilis. — The first symptoms which denote con- 
stitutional involvement rarely appear earlier than the sixth or 
later than the twelfth week after the appearance of the initial 
sore. In some cases their approach is marked by general indis- 
position, weariness, loss of appetite and sleep, a considerable 
degree of nervous tension, and slight fever and headache which 
may be periodic and is usually worse at night. 

The sjrmptoms which are characteristic of secondary syphilis 
are: fever, anaemia, lesions of the skin, hair and mucous mem- 
brane, glandular enlargement, and sometimes affections of the 
eyes and ear. Collectively they constitute the earlier and 
milder lesions of constitutional syphilis, and continue for three, 
or more, months; in all save exceptionally severe cases they 
have run their course by the close of the second year. 

The fever varies greatly. It may be so trifling as to be 
almost imperceptible, or it may be moderate and continuous in 
character, with a temperature only occasionally exceeding 
101°; or remittent, suggesting malarial origin, and often 
treated accordingly; in some of the latter cases the tempera- 
ture may reach 104-°, or more. Sometimes no fever is observed 
until late in the disease. It is almost always worse at the 
breaking-out of an eruption, particularly when of an ulcerative 
or pustular character. 

Anaemia may be so pronounced as to border upon cachexia. 
The number of red blood corpuscles perceptibly diminishes at 
an early period, the percentage of oxyhemoglobin lessens, and 
the number of white blood corpuscles increases. With the ac- 
cession of an eruption these changes in the blood promptly in- 
crease, eventuallj' returning to the normal state with the cessa- 
tion of the second stage. No characteristic organisms have 
been found in the blood. 

The skin presents distinctly characteristic phenomena, em- 
bracing a great variety of eruptions which still have in common 
certain features. The form which is usually first noted is a 
syphilitic roseola, an eruption of reddish-brown hue which 
appears on the chest, front of the arms and abdomen, but 
rarely on the face, and which continues for a fortnight or a 



SYPHILIS. 273 

trifle longer. The papular form consists of groups of acne-like 
indurations about the face and trunk. The pustular form re- 
sembles the eruption of small-pox. The squamous syphilide 
appears like psoriasis, save that the scales are less abundant, 
thinner, less adherent and more superficial, and that the erup- 
tion is not confined to extensor surfaces. All these eruptions 
are accompanied with little, if any, itching or pain; are sym- 
metrical in arrangement; they have a tendency to develop in 
arcs or curved lines; they are of a brownish-red, coppery hue, 
bluish or purplish when occurring on dependent parts; the ulcer- 
ative lesions, spreading by the convex margins and healing in 
the centre, have the shape of a horse-shoe; they leave behind 
them pigmentation; if pustular and ulcerative, the crusts are 
thick, formed in superimposed layers, and are loosely attached. 

The hair falls out in patches, on the scalp, beard, eye-brows, 
eye-lashes, and elsewhere on the body, the result, chiefly, of de- 
struction of the hair-bulbs in the process of the various erup- 
tions. The nails become brittle and crack along their free 
margin; sometimes they are loosened and lost; chronic inflam- 
mation and suppuration of the tissues about the nail occasion- 
ally occurs, tedious in course and followed by the loss of the 
nail. Other changes have been observed, such as a curious 
thickening of the nail, especially at its free margin (hypertro- 
phic onychia). All these are rarely painful. 

Enlargement of the lymphatic glands is more marked during 
the earlier part of the second stage, at the time the eruptions 
first make their appearance, and reaches its full development 
when the eruption is at its height. "All the glands may become 
affected, and the disease is distinguished by the involvement of 
glands which in other diseases usually escape, as the glands be- 
hind the sterno-mastoid muscle and those behind the elbow." 
(Whittaker.) 

The mucous membrane of the mouth and throat becomes hy- 
perasmic, swollen and ulcerated as the fever and eruption ap- 
pear; the ulcers are small, kidney-shaped, and present grayish- 
white borders. The ulceration may become extensive in the 
mouth and throat, even to destruction of the soft palate, epi- 
glottis and vocal cords; it may dip into the trachea and 
bronchi, and is at times observed in the rectum. The so-called 
"mucous patches" are characteristic of this stage. They are 
18 



274 SPECIFIC INFECTIOUS DISEASES. 

round, oval patches, slightly elevated above the surrounding 
healthy tissue, which easily excoriate and ulcerate. When ul- 
cerated, they become moist and are covered by a thin, grayish 
film. Cellular infiltration and enlargement of the papillae may 
be present when the skin is involved. Usually they are not 
painful to the touch; they vary in size from that of the head of 
a pin to an inch in diameter, often coalesce, forming a large 
sore, and are surrounded by a line of thickened and indurated 
tissue. They heal in from six to ten weeks without leaving a 
scar, save if ulceration was deep, in which case there is left a 
glistening cicatrix. Leucomata are whitish spots on the 
tongue; these are often seen in smokers. The "spyhilitic 
warts" or condylomata consist of hypertrophied papillae of the 
mucous membrane frequently seen about the vulva and anus; 
they are caused by friction from clothing or, at times, of op- 
posing mucous patches situated on the buttocks. Among the 
more remote symptoms of this stage are iritis, choroiditis and 
retinitis. Of these, iritis is comparatively common; it usually 
occurs in the early history of the second stage, and, if severe 
and painful, should receive prompt attention. Deafness may 
follow extension of trouble from the throat into the ear. 
Epididymitis has been observed. 

The tertiary form of syphilis, as to the intensity of its mani- 
festations and the stubbornness of its symptoms, depends 
largely upon the care which the patient received during the sec- 
ond stage and upon "constitutional bias." If scrofulous, 
tuberculous, the victim of drink or of extreme poverty, or if 
previously neglected, or if the system is enfeebled from any 
cause, the third stage will probably be tedious and its symp- 
toms severe. If the general health has been good and the pa- 
tient has had intelligent treatment, the attack will probably be 
light, and he may wholly escape tertiary manifestations. 

The characteristic symptoms of this stage are: syphilides, 
gummata, amyloid degenerations, and sclerosis. 

The tertiary syphilides possess features which usually are 
well pronounced. As in the eruptions of the secondary form, a 
number of distinct eruptions may occur simultaneously on the 
body of the same patient (polymorphic), but they are not ac- 
companied by fever. They are often seen in circular spots or 
in crescent-like arrangement, though asymmetric, unequal dis- 



SYPHILIS. 275 

tribution is one of their essential features. Papules are fre- 
quent; they either heal without cicatrizing or they form deep, 
ugly ulcers bearing depressed scars, like "pitting." Syphilitic 
rupia is characteristic. It consists of pustules which scale 
over, break down, and form scales again. The crust is there- 
fore laminated in structure and appearance, like an oyster 
shell. Large pustular lesions not covered in this way are called 
tubercular. They occur most frequently upon the back about 
the sacrum. All these lesions of syphilis destroy tissue and 
leave scars. They are sometimes attended with itching, which 
does not occur in the secondary eruptions. These late manifes- 
tations are not infectious or contagious." (Whittaker.) 

Gummata are inflammatory products which develop in vari- 
ous organs or structures, producing results which differ some- 
what in different locations. Thus, in the skin they break 
down, ulcerate and leave ugly sores which heal slowly and 
with difficulty; the same course is followed in the mucous mem- 
brane, and there cicatrization may result in serious mischief by 
producing narrowing, as in the larynx, or stricture, as in the 
rectum. In the solid organs puckering of tissue and malforma- 
tions are common. 

Gummata may be isolated and circumscribed or diffused; 
more frequently the former. They are nodular bodies, varying 
in size from that of the head of a pin to a small orange, grayish 
in color, firm or soft in consistency, translucent and enveloped 
in granulations or in contracted fibrous tissue. In rare in- 
stances these gummata are slowly absorbed, the skin over the 
site of their former location remaining thin and shrunken. 

The tendency of syphilitic inflammations to caseation and 
cicatrization, with marked contraction of fibrous tissue, is re- 
sponsible for those changes in the affected organs which con- 
stantly come under observation. 

Amyloid degeneration is frequently seen in connection with 
the profound visceral changes peculiar to the tertiary form. 
Sclerosis will be considered incidentally. 

The ravages of syphilis in this stage are so far-reaching and va- 
ried that a more extensive study is necessary to understand 
them. 

Syphilis of the larynx.— In both inherited and acquired 
syphilis the larynx is often involved. In the inherited form this 



276 SPECIFIC INFECTIOUS DISEASES. 

involvement usually occurs early, within the first five or six 
months, or at puberty. Its symptoms are practically those of 
the acquired form, with hoarseness and loss of voice, cough 
with slight expectoration, difficult, sometimes labored, breath- 
ing, in paroxysms threatening actual suffocation or steadily 
progressing to asphyxia. Involvement of the pharynx and ep- 
iglottis is common, and leads to painful, difficult swallowing, 
which in the young child is both distressing and dangerous. 
Deep ulceration, perichondritis or oedema may be present, de- 
manding intubation or tracheotomy. 

In acquired syphilis laryngeal symptoms exist in the second- 
ary and tertiary form. In the former there is erythema, going 
on to subacute laryngitis, with slight loss of voice, inconsider- 
able cough, and other evidences of laryngeal catarrh. Corre- 
sponding involvement of the pharynx and slight glandular en- 
largement (post-cervical) may precede or accompany the 
laryngeal symptoms. In severe cases superficial ulceration, 
surrounded by a deep-red zone, may occur, with muco-purulent 
expectoration; sometimes the ulceration involves the epiglot- 
tis, giving rise to painful deglutition. 

In the tertiary form of syphilis the laryngeal involvement de- 
pends largely upon the presence of gummata and the changes 
which these growths undergo and cause in the surrounding 
structures. Deep ulceration is one of the most important and 
conspicuous. It is accompanied with considerable coughing, 
with copious expectoration of a muco-purulent character, con- 
taining also blood, epithelium, necrosed cartilage and other de- 
bris. Breathing and speaking are seriously impaired as the 
progressive infiltration, the cicatricial and other growths, 
and the oedema encroach upon the epiglottic space, tying down 
the glottis to the pharyngeal wall or fixing the vocal bands, or 
causing paralysis of muscles, or stenosis, possibly stricture, of 
the trachea; the same effect is caused by destructive ulceration 
of the parts. Pain or paroxysms of violent coughing, followed 
by suffocative attacks, may result from a slight effort, and 
may directly or through exhaustion lead to a fatal termina- 
tion. When the ulceration is very deep and involves the car- 
tilage, necrosis and exfoliation are common, and haemorrhage 
may take place from erosion of an artery. 

The deep ulcer, which may be single or multiple, is irregular, 



SYPHILIS. 277 

has raised, ragged edges, its floor is of a dirty yellowish white, 
and it is surrounded by a limited area of slightly inflamed 
tissue. The character of the inflammation is light; there is 
usually absence of severe pain; the parts heal readily, but seri- 
ous deformities often remain, due to cicatricial formations. 

Usually the color of the mucous membrane is of a dark purple, 
sometimes grayish-yellow from chronic changes in the deeper 
tissues; the vocal bands are congested, ulcerated, more or less 
extensively destroyed. Gummata on the epiglottis are pale, 
elsewhere of the dark color of the surrounding membrane, yel- 
lowish in the centre as they approach ulceration. The tendency 
to extensive tissue formation plays an important role here as 
in other phases of syphilitic action. It shows itself especially 
in the parts immediately surrounding an ulcer, and is responsi- 
ble for the deformities which so constantly result. 

The diagnosis from tuberculosis and cancer rests largely upon 
the history of the case, the presence or absence of syphilides, 
and the appearance and character of the ulceration. "Two of 
the distinguishing features of syphilitic ulceration are: The 
usual absence of pain and the inflammatory areola which sur- 
rounds the ulcers; in phthisis the pain may be constant, but ag- 
gravated by deglutition, and the surrounding tissue is rather 
anaemic. In syphilis the superficial ulcers are usually multiple 
and generally oval, with dark-red areolae; those of phthisis, 
though frequently multiple, are usually very irregular in out- 
line. The deep ulcers of syphilis are generally single with over- 
hanging edges, and occupy the sides of the organ; in phthisis, 
on the other hand, the ulcers are not deep, and are prone to at- 
tack the posterior portion. In syphilis, the anterior portion of 
the epiglottis suffers more; in phthisis, the posterior surface. 
The ulcers of syphilis show a tendency to heal readily and leave 
marked cicatricial deformities; those of phthisis heal very slug- 
gishly and leave almost no deformity, the ulcer filling with 
granulation tissue almost as fast as the process of destruction 
goes on. Syphilitic ulceration is an acute process; phthisical, 
usually chronic. The ulcers of syphilis often attack the 
pharynx; those of phthisis rarely. The syphilitic mucous mem- 
brane is purplish; phthisical, anaemic. In phthisis and cancer 
there is usually lancinating pain, which extends along the 
Eustachian tubes to the ears; this is rare in syphilis. Degluti- 



278 SPECIFIC INFECTIOUS DISEASES. 

tion is usually difficult, painful or impossible in phthisis and 
cancer; rarely marked in syphilis except in adenitis. Cancerous 
ulceration requires weeks for its development; tuberculous, 
months; syphilitic, a few days. The anterior and posterior cer- 
vical glands are affected in syphilis; the posterior, rarely in 
cancer and never in phthisis; the anterior may be involved in 
either. More characteristic lymphatic enlargements are found, 
however, at the cornua of the hyoid bone; vety early affected 
in most cases of cancer; late and occasionally in syphilis and 
phthisis. A fibroid degeneration is an infrequent tertiary syph- 
ilitic change; this sometimes undergoes ulceration, from which 
cancer can be best differentiated by consideration of the pre- 
vious history and the coexisting syphilitic lesions. Lupus 
shows some general resemblance to S3 r philis, but it is very rare, 
and always presents other distinctive manifestations." (Ivins.) 

The prognosis is good in the secondary, and serious in the 
tertian,-, form. As to the latter, complications which may 
bring about a fatal result have already been mentioned. If not 
any of these occur, the patient will probably make a good re- 
covery, save impairment of voice and deglutition in case the 
bands were ulcerated or fixed or if extensive destruction of the 
epiglottis had taken place. 

Treatment.— Common sense suggests the necessity of doing 
everything possible to support the patient and to improve the 
general health. Locally, the parts are to be kept scrupulously 
clean. Spraying with sulphate of zinc in gh^cerine or fluid vas- 
eline, five grains to the ounce, is useful in the early stage. Ero- 
sion and ulceration having become established, iodine, in gly- 
cerine or fluid vaseline, five grains to the ounce, is highly rec- 
ommended; it is to be used stronger, even fifteen grains to the 
ounce, in deep ulcerations of the tertiary form. 

The treatment of stenosis by gradual dilatation and of exces- 
sive dyspnoea by intubation or tracheotomy are surgical meas- 
ures which cannot be discussed here. 

The remedies most frequently useful are: Kali iodatum, Kali 
bichromicum, Aurum, Nitric acid, Mercurius. Their indica- 
tions will be given later. 

Syphilis of the nervous system. — Primary syphilitic affections 
of the brain practically consist of the presence of gummatous 
growths or of scattered foci of sclerosis, with a strong tendency 



SYPHILIS. 279 

to undergo fatty degeneration with softening of surrounding 
tissues. The larger gummata constitute tumors of varying size, 
at times exceeding the size of a walnut, more often found in the 
cerebrum, usually multiple, and almost always attached to the 
meninges, preferably the pia mater. When small, they have a 
translucent appearance and are of uniform consistency; when 
large, they are soft and caseous in the centre. The tumors may 
undergo cystic degeneration. The meninges in the neighbor- 
hood of the gummatous tumors become involved in thickening 
and infiltration, especially in the pia mater, and gummatous dis- 
ease of the arteries, running a subacute or chronic course, is 
frequently present. A gummatous peri-arteritis may develop, 
with ovoid nodules in the middle coat of the vessel. 

The secondary brain symptoms either consist of important 
changes which result from the conditions described, including 
softening of the cerebral tissue from extension of the meningeal 
affection, or they are due to arteritis, or to haemorrhage caused 
by weakening and rupture of the walls of the vessels. 

The nerve centres may be affected, especially when syphilis is 
acquired. In the inherited form the symptoms of tumor may 
occur early, in exceptional cases as late as the fifteenth or 
twentieth year. In the acquired form they are among the late 
manifestations, and on this account often perplex the diagnos- 
tician; sometimes, however, convulsions have occurred within 
a few months from the inception of the primary sore. 

The symptoms of cerebral syphilis are practically those of 
cerebral tumor, differing in detail and in the mode of their onset. 
In some cases a change in the mental condition is the first 
symptom observed; the patient is morose, stupid, fails to 
remember common occurrences, and complains of dizziness and 
headache; finally convulsions set in, preceded, often, by delirium. 
In others torpor- is the most striking symptom, with headache, 
eventually culminating in an epileptiform seizure or a hemi- 
plegia. Or dementia paralytica gradually develops, especially 
in cases "where there has been no evidence that the disease had 
concentrated upon any particular portion of the brain; these 
cases may not have convulsions until very late, and it is held 
that they are not amenable to specific treatment. In still an- 
other class hemiplegia, with or without loss of consciousness, 
suddenly takes place, or a train ©f symptoms develops which 



280 SPECIFIC INFECTIOUS DISEASES. 

points toward the existence of a brain tumor, and of which the 
convulsive element overshadows all others. 

The syphilitic headache is one of the most striking and, of the 
earlier, most persistent and characteristic symptoms. It may 
be paroxj^smal, and frequently has well defined periods of max- 
imum and minimum intensity; nightly exacerbations are com- 
monly, but not invariably, present. External tenderness may 
exist when the dura mater or the pericranium are affected. 
The convulsions are those of organic disease of the brain or of 
the meninges, severe and of long duration, and often associated 
with loss of muscular power. Epileptiform convulsions develop- 
ing after the twenty-fifth or thirtieth year are very liable to be 
of sj^philitic origin, — a fact of great practical value. The paraly- 
ses of syphilis are varied, their distribution depending upon the 
area of the brain which is involved. They are complete when 
the result of rupture of a vessel from syphilitic arthritis; other- 
wise the motor function of the involved part is not wholly lost. 
Transient paralyses also occur, with or without loss of con- 
sciousness, at irregular intervals, and pass away quickly. It 
is stated that paralysis of one or more oculo-motor nerves is 
positive proof of syphilitic origin of the paralysis; the same 
applies, with less force, to a cerebral paralysis which follows a 
spinal lesion with a period of health intervening. 

Syphilitic coma, described by Althaus, aphasia, and various 
forms of mental degeneracy are among the conditions which 
may occasionally be seen, but are of interest to the specialist 
only. 

The symptoms of spinal syphilis arise: a) from the presence 
of gummata, of smaller size than those found in the brain, 
attached to the meninges, practically constituting tumors; 
b) from involvement of the spinal meninges, with inflammatory 
changes which give rise to muscular irritation and spasmodic 
action; c) to sclerosis, a late manifestation of syphilis. 

The important points of diagnosis are: history of the case, 
including evidence of priman^ lesion; the multiple character of 
the manifestations; the age of the patient at the time convul- 
sions first appear; the effect of "specific" medication. 

Syphilis of the lungs. — A disease of rare occurrence and ex- 
ceedingty difficult of diagnosis. It is found in the following 
forms: White pneumonia of the foetus. The lung is extensively 



SYPHILIS. 281 

involved, firm, heavy, airless. The alveolar walls are greatly 
thickened and infiltrated; the air cells are filled with desqua- 
mated and swollen epithelium. On section the lung appears of 
a grayish- white, — the "white hepatization" of Yirchow. — Gum- 
mata of different sizes are scattered through the lungs, of gray- 
ish-yellow, cheesy appearance, imbedded in translucent con- 
nective tissue., The bronchi are usually involved, and diffuse 
broncho-pneumonia is seen about the gummata. — A sclerosis of 
the inter-lobular tissue, proceeding from the pleura or from the 
root of the lung, involving a portion or portions of the root of 
the lung, sometimes with the presence of gummata, and known 
as fibrous interstitial pneumonia. 

Syphilis of the Liver. — A syphilitic affection -which is common 
in the inherited, and comparatively frequent in the acquired, 
form of syphilis. The following are recognized: a) diffuse 
syphilitic hepatitis; b) gummata; c) syphilitic involvement of 
Glisson's sheath. 

Diffuse syphilitic hepatitis is very common in the inherited 
form, consisting of an increase of connective tissue, with 
atrophy of the liver cells, scattered foci of "small-celled" infiltra- 
tion, in some cases forming nodules of considerable size and even 
miliary gummata. The liver is yellowish, enlarged, hard and 
resistant, compared by Trousseau to sole-leather. The entire 
liver or parts of the organ only may be involved. 

Gummata in the liver are pale, grayish nodules varying in 
size from that of a pea to a marble, which in the process of 
heeling produce deep scar-like depressions on the surface; these, 
if numerous, give to the organ an appearance somewhat resem- 
bling a bunch of grapes (botyroid). They usually undergo 
fibroid changes, but may soften and form a fluctuating tumor. 

The changes in Glisson's sheath are a thickening of the cap- 
sule which results in peri-hepatitis and increase in the connect- 
ive tissue in the portal canals, the fibrous tissue formation 
often producing deformity of the viscus which is easily recog- 
nized on section. 

The symptoms are those of cirrhosis, -with slight jaundice, 
digestive disturbances, emaciation, and ascites. Great irregu- 
larity in the surface of the liver, after tapping, is strongly diag- 
nostic. Dull, heavy pain, worse from motion, is often present. 
In other cases anaemia is well pronounced; urine is passed freely, 



282 SPECIFIC INFECTIOUS DISEASES. 

and contains albumin and tube-casts. Both liver and spleen 
are enlarged. Dropsy may supervene. After death, amyloid 
degeneration of the spleen, of the intestinal mucous membrane 
and of the liver have been seen, the liver containing gummata. 

The diagnosis of syphilis of the liver depends chiefty upon the 
marked existence of hepatic 'esion, especially enlargement and 
irregularity of the tumor, without serious impairment of the 
general health and the development, incidentally, of character- 
istic syphilitic lesions. 

Syphilis of the Digestive Tract. — The oesophagus is rarely 
involved; if so, stenosis is the most important effect. In the 
stomach gummata are occasionally seen. The stomach, the 
small intestine and the caecum may be the seat of syphilitic 
ulceration. The rectum and anus are often affected. In the 
early stage of the disease erosions about the anus and mucous 
patches, differing somewhat in appearance, are frequently pres- 
ent. In the secondary form ulceration about the anus is common. 
In the tertiary form are found the more serious affections of the 
rectum, especially in women, resulting from the presence of 
gummata in the submucosa close to the internal sphincter; the 
affection is essentially chronic and results in stricture. The 
good general health of the patient, the tedious course of the 
disease, the character of the rectal narrowing, the absence of 
an elevated, crater-like ulcer and of intense pain, establish the 
differentiation between it and malignant disease. 

Syphilis of the heart and blood vessels. — Syphilitic myocardi- 
tis usually occurs as a diffuse fibrous induration. Gummatous 
tumors of the myocardium have been found. In either case the 
results are grave, since sudden death or rupture of the heart 
may occur. Post mortem, recentend ocarditis with wart}' 
syphilitic growths and gummatous and warty growths on the 
valves have been found. 

Arteriosclerosis and aneurism may result from syphilitic 
affection of the vessels. The so-called obliterating endocarditis 
consists of a general infiltration of the inner coats with small 
cells and a proliferation of the subendothelial tissue, giving rise 
to a progressive narrowing and eventual obliteration of the 
entire lumen. The specific character of this affection is deter- 
mined chiefly by the presence of gummata in other parts. 
Gummatous periarteritis consists of the formation of roundish, 



SYPHILIS. 283 

ovoid enlargements in the adventitia of the artery, sometimes 
involving the intima. This infection is distinctively syphilitic, 
involves the smaller vessels, and is often found in the cerebral 
arteries. 

Syphilis of the kidneys and testicles. — Secondary syphilis 
occasionally presents a nephritis, characterized by oedema, 
particularly of the face and eye-lids, malaise, and scanty urina- 
tion. The urine is turbid and rich in albumin; the microscope 
shows the presence of blood-cells and epithelia, and granular, 
epithelial, and blood-casts. Improvement shows itself after a 
short time; hyaline casts take the place of the granular casts; 
the urine becomes normal, and general health appears to be 
restored. 

Gummata are occasionally observed, especially in cases where 
the liver is gummatous. Neither form is of importance clini- 
cally. 

Syphilis of the testes occurs in the form of gummata and 
closely resembles tuberculous disease. The syphilitic affection 
usually is painless, rarely breaks down or suppurates, the indur- 
ation is hard, involves the body of the gland, quite exception- 
ally the epididymis (see tuberculosis of the testicles). An in- 
terstitial orchitis, followed by fibroid induration and atrophy 
of the gland, slowly progressive and painless, has also been 
observed. 

CONGENITAL SYPHILIS. 

Congenital syphilis is in the main characterized by the same 
symptoms which belong to the acquired form. The existence 
of an initial sore is, of course, out of question. In some cases 
the condition of the child at birth is such that it at once 
arouses suspicion. It is poorly developed, badly nourished, 
and often shows an eruption on the skin, usually a pemphigus 
about the wrists, ankles, hands and feet, with "snuffles," sore 
and ulcerated spots about the mouth, fissures, and almost 
always enlarged liver and spleen. The bones frequently are 
diseased, even to separation of the epiphyses. In other in- 
stances the child seems perfectly well, but in a month or two 
syphilitic rhinitis (snuffles) develops, with bloody or sero- 
purulent discharge, progressing to ulceration, necrosis of the 
bones of the nose, and that depression at the root of the nose 



284 SPECIFIC INFECTIOUS DISEASES. 

which is characteristic of congenital syphilis. In the course of 
the affection breathing is impeded and extension of the catarrh 
into the ear may give rise to deafness. As in the acquired form, 
the eruptions play an important part. In this case they are 
erythematous, eczematous, often papular, and frequently red- 
dish-brown patches with well-defined edges, which almost 
always first appear about the nates. Syphilitic rhagades, 
fissures about the angles of the mouth, sometimes in the 
median line, develop next, with discharges that are exceedingly 
virulent and dangerous to any surface with which they come 
in contact. Falling out of the hair, eye-brows, and lashes, and 
affections of the nails now appear, with only slight glandular 
involvement. Restlessness, malaise, and sleeplessness accom- 
pany the symptoms. 

The bone-lesions of congenital syphilis, consisting of a chronic 
gummatous periostitis, usually show themselves after the sixth 
year. They affect the long bones, preferably the tibiae. The 
nodes are symmetrically arranged, lead to great thickening of 
the bone, and are not usually painful. Affections of the eye, 
keratitis and iritis, and of the ear, the latter generally result- 
ing in deafness, set in about the period of puberty, and later; 
sometimes the bone lesions first appear at this time, or even 
later. Enlargement of the spleen, a syphilitic synovitis affect- 
ing the knee, and gummata of the liver, kidneys and brain, have 
also been observed. 

The general health of the child, especially its nutrition, may 
either remain unsatisfactory or what seems like complete re- 
covery may take place. Yet, many high authorities point out 
the fact that even in the latter condition certain marks of 
syphilis remain which are readily recognized; they are so-called 
"infantilism" and an appearance of the teeth which Jonathan 
Hutchinson claims is characteristic of congenital syphilis. The 
term ''infantilism, " first used by Fournier, is self-explanatory; 
it refers to peculiarities of the face and skull which give to the 
patient, arrived at years of almost maturity, the expression 
and appearance of a young child, which is intensified by actual 
backwardness in intellectual development. As to the teeth of 
congenital syphilis, the permanent upper central incisors are 
peg-shaped, stunted, narrower at the cutting edge than at the 
root. The enamel on the anterior surface is perfect, but the 



SYPHILIS. 285 

cutting edge is disfigured by a single notch of varying depth, 
in which the dentine is exposed. 

The prognosis of congenital syphilis is grave. Kassowitz 
states that of syphilitic children one-third die before birth and 
one-third before the age of six months. The late manifestations 
are a constant menace to life and usefulness. The treatment 
is largely symptomatic, such remedies as Mercurius, Nitric 
acid and Aurum being most often indicated. Of the mercurial 
preparations, the milder salts, in young infants, are to be pre- 
ferred. Inunction with mercurial salve is practiced by means 
of a flannel binder upon which the ointment has been spread, di- 
rectly applied to the abdomen of the infant, and allowed to 
remain for two or three days; it is then removed, the 
child carefully w ashed, and the ointment reapplied. This 
treatment must be discontinued as soon as warranted by im- 
provement of the case. Iodide of potassium is the recognized 
specific for the latent manifestation; Gilbert's syrup, i. e., Merc, 
biniod., gr. 1, Potass, iodide, §ss., -water, oz. ii., 5 to 10 drops 
three times per day, the dose being gradually increased and the 
remedy continued for many months, is an excellent prescrip- 
tion for late manifestation with bone lesion. 

The General Diagnosis of Syphilis. — In addition to the 
diagnostic symptoms already pointed out, the diagnosis 
depends upon extreme care and thoroughness in the exami- 
nation of the case and of its entire history. The patient's 
own statements can never be considered conclusive. In 
women who habitually abort a persistent search must be 
made for proof of primary lesion, for affections of the skin and 
hair, scars in the throat and groin, or for traces of bone disease, 
etc. Osier points out the fallacy of the old teaching that relief 
in a case of suspected syphilis obtained by the exhibition of iodide 
of potassium is proof of the syphilitic origin of the case; he 
states that in several cases thus treated improvement followed, 
but ' 'the subsequent course and the post mortem have shown 
that the disease was not syphilis." 

The prognosis of acquired syphilis, so far as it concerns even- 
tual recovery, is surprisingly encouraging when we bear in 
mind the seriousness and the complexity of its manifestations. 
Individual susceptibility plays an important role in the severity 
of these manifestations. Thus, a seemingly healthy person may 



286 SPECIFIC INFECTIOUS DISEASES. 

become infected, have skillful treatment, and yet become the 
victim of frequent and unexpected relapses, while another, 
appearing less healthy and having indifferent treatment, suffers 
but little and makes a good recovery. Experience shows that 
a trifling manifestation of secondary symptoms is often followed 
by violent tertiary symptoms. 

The Treatment of Syphilis. — Proplrylaxis may be summed 
up in the brief sentence "personal sexual purity." Constant 
hard work at some absorbing occupation, regular hours and 
desirable associations are important aids in bringing about 
such a result. But sexual passion is not easily controlled, espe- 
cially when opportunities abound for its gratification, and ar- 
guments have little weight when offered at the moment of in- 
tense sexual desire. It is nevertheless proper that medical men, 
as persons experienced in the ways of the world, should call the 
attention of men to the value of continence in its bearing upon 
the physical and moral welfare of the individual, the danger to 
self incurred by sexual immorality, the possibility of syphilitic 
infection, and the frightful responsibility of perchance entailing 
upon still unborn children so hideous an inheritage as is syphilis 
in any form. To the young man who aspires to a pure and 
happy home of his own, it may be wise to point out that the 
truly happy husband is he who has never been locked in the em- 
brace of any woman save his wife, for to that man no woman 
but the wife has it in her power to gratify the fulness of his 
desire. 

Equally important is the question of controlling, by police 
regulation, the so-called social evil. A physician should not 
deal with the sentimental side of this question, but should 
strive to educate the masses so they will indorse and second ef- 
forts in that direction. Let it be understood that the woman 
who sells her body for a money-consideration shall do so 
openly, that she may make this consideration proportion- 
ate to the charms sold, but that she must go into retirement 
when she becomes diseased. The woman who by choice or ne- 
cessity lives an open life of shame is less an enemy to society 
than she who does so secretly, and venereal and syphilitic af- 
fections are less often propagated in the house of open prosti- 
tution than in the bed of the woman of loose virtue who yet 
attempts to wear an ill-fitting cloak of respectability. Leg- 



SYPHILIS. 287 

islation cannot make, and never will make, people pure; but it 
can somewhat reduce the mischief wrought by impurity of life. 

The possible marriage of a syphilitic must also be considered. 
It should never be allowed until two, still better three, years 
have elapsed since the primary infection and at least one year 
since the latest manifestation of syphilis. 

The drugs which have made the most remarkable record in 
the treatment of syphilis in the hands of the general profession 
are Mercury and Iodide of Potassium; when the latter is not 
kindly borne, the iodide of sodium is substituted for it. What- 
ever the remedy, the treatment must always be continued for a 
period of from one to two years, or longer. 

Mercurius appears to be an almost specific for the secondary 
form. It may be given by the mouth, by inunction, under the 
skin, or by fumigation. The last two methods offer no partic- 
ular advantage and entail unnecessary inconvenience. When 
given by the mouth, according to the dosage of the physiolog- 
ical school of to-day, the biniodide of mercury is preferred in 
doses of one-sixteenth of a grain, the protoiodide in doses of one- 
fifth of a grain, three times daily. Hydrargyrum cum creta is 
administered in one-grain doses, with equal parts of Dover's 
powders, from four to six times daily. If the drug is used in 
form of an inunction, one drachm of mercurial ointment should 
be thoroughly rubbed into the skin, on the inner surface of the 
arms or thigh, or on the abdomen or sides of the chest, for six 
consecutive evenings; a bath is taken on the seventh evening, 
and the inunctions recommenced on the eighth evening; this 
treatment is continued until there is relief or until salivation 
threatens. Special precautions must invariably be taken to 
avoid salivating the patient; the gums especially must be 
watched for indications of mercurial poisoning. 

The tertiary stage, in all its manifestations, has been most 
successfully treated by the Iodide of Potassium (or the Iodide 
of Sodium). The most varied syphilitic lesions have been cured 
under its exhibition. The doses given must be not less than ten 
grains three times daily, and must be gradually increased until 
thirty-grain doses are taken. The most experienced specialists, 
men whose success and knowledge cannot be called into ques- 
tion, urge the necessity of large doses, especially when there is 
syphilis of the nervous system. 



288 SPECIFIC INFECTIOUS DISEASES. 

Physicians who base their prescriptions upon the "law of the 
similars" may justly claim that in very many cases the symp- 
toms clearly call for the exhibition of mercury or of the iodide 
of potassium, and that in such cases satisfactory results have 
been obtained from the exhibition of very minute doses of these 
drugs. It seems probable that these minute doses act as spe- 
cifically as do the larger doses of the physiological school, sim- 
pry because the preparations employed have been subjected to 
a process of long-maintained trituration and minute subdivi- 
sion which enables them to enter more readily into the system 
and to produce their specific healing effect in a shorter time, 
more permanently, and without producing the physiological 
effects which often result from material doses. 

Mercury. — Mercurius biniodatus. One of the most useful 
mercurial preparations when the soft parts of the throat are 
extensively involved, especially on the left side, and when the 
ulceration is rather superficial; the tongue is clean or coated 
3'ellow. — Mercur. protoiodatus: S3'philitic iritis. Involvement 
of the posterior wall of the pharynx, tonsils, etc., worse on the 
right side; empty swallowing; copious flow of saliva; the 
glands of the neck are hard and swollen; sticking, tearing, bor- 
ing pains in the limbs, usually worse at night, in bed. — Mercu- 
rtus dulcis: A good remedy in infantile syphilis; face pale and 
looks like the face of a corpse; enlargement of the liver; oral 
mucous membrane pale, ulcerated; fetor from the mouth; sali- 
vation; small phagedenic ulcers in the mouth and on the 
tongue; coppery eruptions on the body.— Mercurius corrosi- 
vus: Fever and pain accompany the symptoms. Ozaena, with 
ulcerated nasal mucous membrane; great burning soreness; 
thick, gluey, excoriating discharge; mucous patches in the 
mouth, with burning pain; ulceration of throat and soft parts, 
with great soreness; grayish ulcers, with burning pain, difficult 
swallowing, offensive breath. Syphilitic laryngitis. — Merc, 
nitric: Superficial ulceration, with splinter-like pains. Mucous 
patches in the mouth. — Kali iodat.: Profuse acrid coryza, with 
throbbing and burning in the nasal and frontal bones; dis- 
charge of thick, yellow mucus from the nose; deep ulceration 
in the throat, with glandular involvement. Syphilides, espe- 
cialh' of papular character. Gnawing, boring bone-pains. — 
Kali bichromicum is one of the most useful remedies. "It has 



SYPHILIS. 289 

cured deep ulcers on the edge of the tongue, ulcers of the mouth 
and fauces; syphilitic laryngitis with dry, hoarse, hacking 
cough; fetid discharge from the nose; pustular syphilides; 
suppurating tubercles, forming deep, circular, 'punched-out- 
looking' excavations; caries of the bones of the nose; bone- 
pains with stitches, as if from sharp needles wandering all over 
the body (Trites in Arndt's System)." It is of great value in 
nasal involvement of infantile syphilis, with a tendency to per- 
foration from ulcers; in the pustular form of syphilides the 
ulceration goes on beneath the scab; it always dips deep into 
the tissue; does not spread laterally. — Phytolacca has many 
throat symptoms, usually accompanied with glandular en- 
largement, which suggests its use in syphilitic ulcerations of the 
throat; the parts are dark, livid, purple; swallowing is exceed- 
ingly painful and accompanied with intense tearing, shooting 
pain through the ears. These symptoms warrant its exhibi- 
tion in secondary syphilis. Its chief value, however, depends 
upon its remarkable action in "bone-pains," when the long 
bones are affected, with continuous deep, burning pain. Syphi- 
litic rheumatism, tearing and shifting, if in the joints, with red- 
ness and swelling, always with aggravations during damp 
weather. Syphilitic headache, of similar character, with deep, 
internal soreness and, at times, a sense of constriction. — Aurum 
metallicum has well-deserved reputation in the treatment of 
ozama when the discharge is thick and exceedingly offensive, 
with much swelling of the parts and loss of smell. It is of 
value when the flat bones (palate, nasal, frontal, mastoid, etc.)' 
are affected with burning pain, fetid discharge, tendency to 
caries and necrosis. It seems to act best in persons of fair com- 
plexion, in children and old people, and when there is great 
melancholy and depression.— Asa fcetida is one of the best 
remedies in affections of the long bones, especially of the tibise, 
"with a tendency to destructive processes. The pains are in- 
tense and of a throbbing character, sometimes cramp-like; the 
parts involved are very sensitive. It acts well in ulceration of 
the skin, very sensitive to the touch, with discharge of thin 
ichorous pus. After the abuse of mercury. Often the nervous 
symptoms of the remedy furnish important indications. — Nitric 
acid is used in ulceration of the mouth and throat, flat and 
spreading laterally, bleeding when touched, even though very 
19 



290 SPECIFIC INFECTIOUS DISEASES. 

gently, with much salivation, soreness and splinter-like pain 
when swallowing. Ulcers on any part of the body, presenting 
these characteristics, point to Nitric acid. It resembles Mer- 
cury in the nightly aggravation of its constrictive headache, 
"as if in the bones of the head;" it has bone-pains at night, 
worse from change of weather and dampness, caries of the flat 
bones (with splinter-like pains). Condylomata, copper-colored 
spots on the body, especiahV about the anus and on the chest.— 
Fluoric acid is useful in deep destructive processes; hence its 
value in syphilitic ozaena, caries and necrosis of bones, deep ul- 
ceration of the throat with much infiltration, great fetor, sen- 
sitiveness to cold, onychia, ulceration about the nails and 
phalanges of the fingers. The patient suffers much from boring, 
burning pain, which keeps him constant!}*- "on the move." The 
discharges are thin and acrid. It has proved valuable in the 
syphilis of young children. — Mezereum has made a good record 
in relieving syphilitic bone pains. "In the mercurio-syphilitic 
diseases of the periosteum, periostitis, nodes, periosteal rheu- 
matism; intense burning pain in the bones, worse at night; 
dark-red inflammation of the pharynx, with burning dryness; 
huskiness of the voice, with hawking up of mucus, worse in 
cold weather (Trites). 

Remedies of less importance clinically are: Thuja (secondary 
form; condylomata; roseola; iritis, with gummata on the iris 
and severe nocturnal pain; rhagades); Arsenicum iodatum 
(cachexia; gummata); Phosphorus (general tendency to fatty 
degeneration of organs; marasmus; headaches, with falling of 
the hair in circumscribed spots; exostosis of the skull, with vio- 
lent tearing pain at night; necrosis of bones; painful laryngitis; 
locomotor ataxia; S3'philitic psoriasis and roseola); Lachesis, 
Hepar sulphur., Silica, Badiaga, Stdllingia sylvatica 
(sA'philitic eruptions of the secondar\>- and tertiary form, of 
torpid, scaly, obstinate character; moist, brown, excoriating 
eruptions on the scalp; syphilitic ulcers; dark-red, tubercular 
eruptions, with unhealthy ulcerations; bone pains, with no- 
dosities on the skull and long bones); Kreasotum (tertiary 
form; burning pains like red-hot coals). 



RABIES. 291 



RABIES. 



Rabies, commonly called hydrophobia, is an infectious disease 
of frequent occurrence in animals, especially in the wolf, dog 
and skunk, more rarely in the fox, cat, horse, and cow, which 
may be communicated to man through inoculation from the 
bite of an infected animal. 

Practically nothing is known of the nature of the poison of 
rabies save that it is met in the saliva and blood, that it can 
be successfully inoculated, and that it acts upon the central 
nervous system. The disease, as it occurs in man, almost al- 
ways results from the bite of a dog or, in the West, of a skunk. 
Violent as is the action of the poison, not all persons bitten 
have rabies; owing to personal immunity and to imperfect in- 
fection, about one-half of the persons bitten by an infected 
animal escape. An infected animal may communicate the dis- 
ease throughout the entire period of incubation. The seat of 
the infection is usually an exposed part of the body, as the 
head, face, arm or leg. 

The period of incubation in man is exceedingly indefinite; in 
all cases it is remarkable for its length. In sixty per cent, it 
varied from eighteen to sixteen days; in thirty-four per cent, it 
exceeded two months; there are on record well-authenticated 
cases where rabies occurred from three months to a year, and 
even two years, after infliction of the bite. 

Morbid Anatomy. — A perivascular accumulation of leuco- 
cytes, most marked about the vessels of the medulla and cortex 
and in the upper cord, was observed by Gowers in seven out of 
nine cases which he examined. The pharynx, larynx, trachea 
and bronchi are usually congested; the stomach often is hyper- 
semic. Minute haemorrhagic effusions, especially in the medulla, 
have been noted in the brain. The lungs are congested, some- 
times cedematous. Heart, liver and spleen are normal. 

Clinical History. — The premonitory (psychical) stage is char- 
acterized, often, by radiating pain or anaesthesia about the 
seat of the injury, although the wound may have, and usually 
has, perfectly healed; at times the wound reopens. Indisposi- 
tion, loss of appetite, restlessness, irritability, sleeplessness, and 



292 SPECIFIC INFECTIOUS DISEASES. 

a sense of some impending misfortune oppress the patient, ren- 
dering him profoundly melancholic. The special senses are ex- 
cited, and a trifling disturbance, as a sudden bright light or a 
noise, cause great distress. The characteristic fear of water 
may show itself on the first day or later; the patient may 
suffer from thirst, but cannot drink, either because the act of 
swallowing is actually difficult or because he has a dread of at- 
tempting it. There is also burning and a sense of constriction 
in the larynx, often with huskiness of voice. After one or two 
days, the furious (spasmodic) stage sets in, chiefly marked by 
violent spasmodic action involving thelarjmx and pharynx, but 
also the muscles of respiration and those of the trunk and ex- 
tremities. Every attempt to swallow water brings on violent 
spasms, and even the sight of it may throw the patient into 
convulsions. The convulsions last from a few minutes to half 
an hour; they occur at gradually lessening intervals, are ac- 
companied with intense anxiety and oppression, and in many 
cases with strange sounds proceeding from the patient, like a 
hoarse bark, caused by the violent contractions of the laryn- 
geal and pharyngeal muscles. "Any afferent stimulant, i. e., a 
sound or a draught of air, or the mere association of a verbal 
suggestion, will cause a violent reflex spasm. In man this 
symptom constitutes the most distressing feature of the 
malad}'. The spasms, which affect particularly the muscles of 
the larynx and mouth, are exceedingly painful and are accom- 
panied by an intense sense of dyspnoea, even when the glottis 
is widely opened or tracheotomy has been performed" (Hors- 
ley). Intense thirst and burning pain in the throat torment 
the patient, from whose mouth saliva may issue in a copious 
stream; the pulse becomes rigid and full; the temperature rises 
to 101°, or more, scarcely ever exceeding 103°, and delirium 
and mania rapidly develop. It is remarkable that very often 
the patient, even though laboring under furious excitement, 
preserves a consciousness of his condition and of the danger 
to others of any injury he may inflict upon them, and exercises 
great control over himself not to bite or otherwise wound his 
attendants. The convulsions and suffering increasing in fre- 
quenc\- and intensity, the patient may die during the height of 
a spasm within one to three da3 T s. If death does not occur in 
this stage, the so-called stadium paralyticum supervenes, the 



RABIES. 293 

utterly exhausted patient rapidly drifting into a condition of 
hopeless prostration, characterized by a gradual cessation of 
the spasms, weak and fluttering pulse, and death from syncope 
in from six to eighteen hours. 

The diagnosis generally is easy. It rests chiefly upon the re- 
flex character and nature of the convulsions. Rabies resembles 
tetanus, but lacks the trismus and opisthotonos of the latter, 
also its characteristic micro-organism; the period of incubation 
in tetanus is from three to ten days after the receipt of the in- 
jury, that of rabies much longer (see above) . The diagnosis 
from lyssophobia, or fear of hydrophobia, a nervous disorder 
of not infrequent occurrence even among persons of strong 
will force and good judgment, may be difficult. In these cases 
the symptoms, though often of sufficient violence to demand 
the most careful attention and possibly resulting fatally from 
exhaustion, nevertheless lack much of the intensity of true 
rabies; hence the patient will safely pass the limit of the dura- 
tion of true hydrophobia, a fact which in itself can be used to 
assure the sufferer of the harmlessness of his symptoms. Proof 
that the animal which inflicted the bite was not diseased is 
usually sufficient to quiet the fears of the sick one. 

The prognosis in man is fatal. Wounds on the face are the 
most serious. Yet, Bollinger claims that of 200 human beings 
in France bitten by rabid animals, 133 were cauterized, and 
that of these 92 (i. e. 69 per cent.) remained healthy; of those 
not cauterized, 83 per cent, died of rabies. 

Prophylaxis. — Since in nearly every case of rabies in man in- 
oculation proceeds from the bite of a dog, a law compelling 
owners of dogs to keep them muzzled, on pains of having the 
animal shot on sight, would undoubtedly prove an amply suf- 
ficient preventive. 

Treatment. — Treatment of the wound consists of disinfection 
and prompt and thorough cauterization by nitrate of silver, 
caustic potash, the red-hot iron, or the electric cautery. If this 
cannot be had at once, attempts should be made by the injured 
person himself or others to eliminate the poison by sucking the 
wound; it must not be forgotten that this measure might prove 
disastrous in case of anabraded surface about the lips or mouth. 
A ligature properly applied may prevent absorption. The appli- 
cation of a solution of corrosive sublimate (1:500 or 1:1000) 



294 SPECIFIC INFECTIOUS DISEASES. 

has been highh' recommended. Excision of the injured parts or 
amputation of the wounded limb, in case of extensive lacera- 
tion, may become necessar} 7 . The wound, according to some 
authorities, should be kept open for a period of, at least, six 
weeks, and if the surgeon is not consulted until healing has 
taken place, excision of the scar, including any swollen lym- 
phatic glands in the neighborhood of the bite, should be 
promptly performed. Turkish baths have been advised during 
the period of incubation. 

Under all circumstances no pains should be spared to draw 
the attention of the injured person from himself and to exclude 
ever3 r thing that might aggravate his dread of possible serious 
consequences. 

If symptoms of rabies have developed, confinement in a dark- 
ened room under the care of properly instructed attendants, 
not more than two at a time, with the use of morphine in ap- 
propriate doses, has been the standard treatment, chloroform 
being emplo} T ed to lessen the violence of the spasms, and co- 
caine, locally, to relieve the hypersensitiveness of the throat. In 
view of the great difficulty of swallowing, it may become 
necessary to administer concentrated food per rectum. 

Pasteur's Method.— Pasteur found that inoculation from 
rabbit to rabbit, continued from animal to animal through 
many generations, vastly increases the intensity of the virus, 
eventually reducing the period of inoculation to seven days. 
Dessication of the medulla of an animal treated with the most 
active virus in sterilized glass vessels in which pieces of caustic 
soda had been placed, reduced the virulence of the virus until it 
eventually became innocuous. Beginning with injections of 
this non-virulent medulla, followed with injections of emul- 
sions of medullas of increasing virulence, up to medullas which 
had been dried only one or two days, he succeeded in rendering 
dogs thus treated absolutely immune to infection with the 
virus of rabies. Practically the same plan, i. e., inoculation be- 
ginning with weak preparations and repeated with stronger 
preparations of the medullas of rabbits inoculated as described, 
is followed by Pasteur in the treatment of persons bitten by 
suspected animals. Of late, Tizzoni and Centanni, of the Uni- 
versity of Bologna, have extracted a chemical vaccine from the 
central nervous system of rabbits dead from fixed virus, from 



RABIES. 295 

which they hope to obtain both immunity against infection and 
prevention of the disease after infection even when its initial 
symptoms have appeared. 

As yet, opinions differ concerning the value of results actually 
obtained. Thus, the Society for the Protection of Animals 
from Vivisection, up to June, 1892, reports a list of 230 per- 
sons who died from hydrophobia after they had received treat- 
ment at some Pasteur Institute. On the other hand, Pasteur 
himself, in 1892, claims to have treated 1793 persons with only 
seven deaths, and of these three occurred from hydrophobia de- 
veloping within fifteen days after the beginning of treatment. 
From 1886 to 1892, 12,782 patients were treated in the Pas- 
teur Institute, with sixty-eight deaths, an average of 0.52 per 
cent. 

Internal specific medication, at the hands of any school of 
practice, has accomplished little, though an attempt to class as 
lyssophobia all cases of reported cures of rabies, simply because 
cures were claimed, appears unwarranted. Cures have been re- 
ported under Belladonna (violent congestion, flushed face, 
brilliant and congested eyes, with dilated pupils and star- 
ing expression, throbbing pulse, hoarse, barking voice, spasms 
of the throat, inability to swallow, violent delirium, mania, 
strikes and bites, and attempts to get away), Hyoscyamus, 
Stramonium, Cantharides and other remedies. 

Hydrophobia or Lyssin, introduced by Hering, may prove 
valuable, just as variolin has proved a most excellent remedy 
in variola. — Kuhner relates a case where a person violently ill 
from rabies devoured a piece of the root of Spir^a ulmer; a 
quarter of an hour afterward he became conscious, vomited gall, 
and slept profoundly for twenty -four hours, awaking recovered. 
— Ghose reports a case cured by eleven subcutaneous injections 
of Pilocarpine hydrochloride, \ grain each, in the course of 
seven days. He excised the scar and kept the wound open for 
two weeks previously, thus relieving the pain in it.— S. Kotack 
(Indian Med. Record) saw a remedy given to no less than 
thirty persons within a month after having been bitten by 
rabid dogs. In no case had rabies developed after a year. It 
proved to be an insect of the cantharides family, closely related 
to, but not identical with, cantharides vesicatoria; its adminis- 
tration in all the cases caused difficult and painful micturition, 



296 SPECIFIC INFECTIOUS DISEASES. 

with the passage, from the urethra, of a number of polypoid 
bodies.— Goss, of Georgia, claims to have had curative action 
from Echinacea angustifolia, a teaspoonful of the tincture 
three times daily, and from Scutellaria, sixty drops of the 
tincture every three hours. He cites several cases successfully 
treated with one or both of these remedies. 



TETANUS. 

Tetanus, also cailed trismus or lockjaw, is an intensely acute 
infection, due to inoculation with the tetanus bacillus through 
a wounded or abraded surface, characterized by tonic spasms 
of the muscles, the result of intense irritability of the reflex 
centres in the medulla and cord due to the physiological action 
of the toxins of the specific bacillus. The disease is of short 
duration and rapidly tends to a fatal termination. 

/Etiology. — Tetanus, in the large majority of cases, results 
from trauma; it may be idiopathic. — The wound inflicted is of 
a trivial nature, such as is caused by running a splinter into the 
hand, a nail penetrating the foot through the sole of the boot, 
the sting of an insect, the abrasion of the surface from a blow 
or a fall, or the extraction of a tooth. Contused or punctured 
wounds are much more dangerous than cuts; gun-shot wounds 
frequently cause lockjaw; injuries to the nerves are still 
classed among the important exciting causes. Injuries of this 
class are most frequently sustained on the extremities, and sta- 
tistics show that in a majority of cases trismus has resulted 
from hurts to the fingers, hands, or legs. The disease occurs 
oftener in hot countries than in temperate climates, and shows a 
striking preference for the colored races. It is comparatively 
frequent among the new-born (trismus neonatorum), and the 
mortality' from this source among the negroes of some of the 
West India islands destroj-s almost one-half of their entire in- 
fant population. It is very probable that the raw umbilical 
surface is the seat of the specific infection. Aside from the 
tetanus of the new-born, the affection is most frequentl}- seen 
from the tenth to the thirtieth year, and oftener in males than 
in females, owing to the greater liability on part of boys and 



TETANUS. 297 

men to injuries and to exposure. Idiopathic tetanus results 
from exposure, such as sleeping on damp ground, and is of rare 
occurrence in man. 

The bacillus of tetanus was discovered in the soil by Nicho- 
laier in 1885, in man by Rosenbach, in 1886. It forms a slender, 
delicate rod which swells on one end, presenting an oval, 
sharply defined, shining spore, thus resembling a drumstick or 
pin. The bacilli occur in regular masses in the affected tissues, 
are easily colored with methyl blue and fuchsin, and are not 
readily cultured. Brieger (1887) separated from the culture, 
and from a subject dead of tetanus, various toxins, of which 
one, tetanin, causes the characteristic symptoms of tetanus, 
with fatal termination. 

The disease may be transmitted to animals by inoculation 
with the culture, and protection may be insured by inoculation 
with the blood of an animal which has had the disease. 

The bacillus is motile, grows at an ordinary temperature, and 
is anaerobic, that is, capable of existing only in a medium desti- 
tute of free oxygen. It is widely disseminated in the soil, both 
inhabited and virgin, especially in the dust, dirt, and rubbish 
about houses. "The wide dissemination of the parasite ac- 
counts for the cases of apparent spontaneous or idiopathic 
tetanus, while the fact that the free access of oxygen prevents 
its growth furnishes explanation of the comparative rarity of 
the disease and the greater liability of penetrating wounds." 
(Whittaker.) 

Morbid Anatomy. — No characteristic changes have been ob- 
served in either brain or cord. A slight degree of congestion, 
with granular changes in the nerve cells, is frequent. The 
wound itself commonly presents evidence of slight inflamma- 
tory action. 

Symptoms — The symptoms of tetanus usually occur within 
ten days, rarely more than fifteen days, after the injury. They 
consist of violent spasms, which begin mildly, increase gradu- 
ally, and progress from above downward. Occasionally ma- 
laise, shivering, pain in the epigastric region and at the seat of 
injury constitute a sort of prodroma; but much oftener the 
first symptom of which the patient complains is a stiffness 
about the neck, with feeling of tightness about the jaw, rapidly 
developing into tonic spasms of the muscles of mastication, 



298 SPECIFIC INFECTIOUS DISEASES. 

and constituting trismus or lockjaw. The muscles of the face 
soon become involved; the lips are stretched over the locked 
teeth, and the e3^e-brows are raised, producing risus sardonicus, 
the appearance of the face becoming grotesque and much aged. 
With this state there is usually much difficulty of swallowing. 
The case progressing, the muscles of the trunk jaeld next, the 
body assuming various well-marked fixed positions. The entire 
body may lie rigid, like a statue (orthotonos); or it may be 
arched, with its convexity upward, so much so, at times, that 
only the back of the head and the heels touch the couch (opis- 
thotonos), the abdominal muscles sometimes actually being- 
torn in two from the terrible strain put upon them; or the 
body, more rarely, is violently flexed to one side (pleurosthot- 
onos) or bent forward by spasm of the abdominal muscles 
(emprosthotonos) . 

Convulsive attacks with lightning-like shocks sometimes take 
place during these tonic spasms, and patients occasionally com- 
plain of shocks like those caused by a strong electric current 
at various stages of the disease, especially before the occurrence 
of violent spasms. The extremities, especially the arms and 
hands, become involved late. 

The suffering of the patient is extreme; perfect relaxation 
and rest of the weary muscles does not occur during the inter- 
vals, and the most trivial cause, as a slight voluntary effort, a 
touch, even a suggestion brings on a new spasm. The chest 
becomes compressed from spasms of the thoracic muscles, ren- 
dering respiration rapid and labored, often with severe lanci- 
nating pain in the lower chest from involvement of the dia- 
phragm; asphyxia is threatened from spasm of the glottis; 
neither drink nor food can be taken save under most distressing 
conditions, and may have to be administered per rectum; speech, 
also, is impossible, and the patient, entirely conscious through- 
out, lies in indescribable agony, unable to obtain a moment's 
perfect relief from intense suffering, usually bathed in profuse 
sweat, with stubbornly constipated bowels, and urine retained 
or suppressed. 

The temperature varies. It may be normal thoughout, with 
a slight rise before each aggravation of the spasms and a more 
marked elevation toward the termination of the case; or it may 
be quite high from the beginning, especially so in cases where 



TETANUS. 299 

there has been a distinct rigor on the start, reaching 105°, or 
more, with an elevation before death to 109° or 110°, and even 
higher. Death results during a spasm from asphyxia or heart 
failure, or from sheer exhaustion. 

Diagnosis. — The most important symptoms for diagnostic 
purposes are: The history of an injury, the early appearance of 
trismus, and the absence of periods of freedom from suffering- 
Of these, the early appearance of trismus is the most valuable. 
"The feel of the rigid masseters inside the mouth, and the asso- 
ciate stiffness at the back of the neck, speedily dissipate 
doubts." Hysteria may resemble tetanus, but only vaguely; 
the history of the hysterical case, the irregularity and fitfulness 
of the hysterical convulsions, and the periods of rest which are 
bound to occur, will establish the diagnosis. The various affec- 
tions of the brain which resemble tetanus very rarely, if ever, 
have trismus. Hydrophobia has a much longer period of incu- 
bation, lacks trismus and opisthotonos, and presents a charac- 
teristic psychical picture essentially its own. Poisoning with 
strychnia presents a striking resemblance to tetanus, but there 
is lacking the history of an injury; its symptoms appear almost 
immediately after the poison has been taken; there are severe 
gastric symptoms; the muscles of the extremities are attacked 
at once, in tetanus these become affected late; it does not cause 
trismus as an early and characteristic symptom, and it has dis- 
tinct periods of rest between the spasms. 

The prognosis is very serious; an estimate of a mortality of not 
less than eighty percent, in traumatic tetanus and of about fifty 
per cent, in the idiopathic form is generally accepted as correct. 
Hippocrates gives a favorable prognosis in cases that have 
safely passed four days, and experience has demonstrated that 
he was correct. The mortality is greatest among children. 
Late onset of the disease, absence of fever, and limitation of the 
spasms to the muscles of the neck and jaw make the prognosis 
less grave. Improvement shows itself by a lessening in the fre- 
quency and severity of the spasms and increasing tendency to 
rest during the intervals. 

Treatment. — Prophylaxis consists of great care of such in- 
juries as may cause tetanus, especially in the removal of earth 
or dirt which may adhere and in the employment of strict anti- 
sepsis. Excision of injured parts or amputation is still advised 



300 SPECIFIC INFECTIOUS DISEASES. 

as a means of lessening the clanger of autoinfection, but has 
ceased to be generally recommended; in fact, it is admitted that 
amputation has been the direct cause of death b^^ further ex- 
citing tetanic spasms. The serum treatment of Tizzoni and 
Centanni, and of Roux, is now the subject of extensive study, 
but the results obtained are not yet conclusive. 

Absolute rest in a dark room, under the care of one well- 
trained attendant who will move about noiselessly and prevent 
anything likely to excite reflex action, is of the greatest possible 
importance; it is even urged that the ears of the patient be 
stopped up with cotton. As soon as swallowing becomes diffi- 
cult, liquid food should be given exclusively, and feeding per 
rectum must be diligently maintained as soon as deglutition 
has become impossible. The use of chloroform during the 
spasm has been earnestly advocated, but excellent authorities 
not only deny the wisdom of this practice, but insist upon its 
being harmful, preferring that the patient be kept under the in- 
fluence of full doses of morphia hypodermically administered. 

Chloral, Calabar bean, Cannabis Indica, Curare, 
Strychnia and Belladonna are the chief remedies used by the 
profession at large; the inefficiency of this treatment is gener- 
ally admitted and attaches especial interest to the experiments 
made with the serum or antitoxin. 

Nux vomica (Strychnia, Ignatia), by the striking similarity 
of its pathogenesy to the symptoms of tetanus, the violence of 
its convulsions, tonic rigidity of the muscles, intensely stimu- 
lated reflex action, difficult respiration and threatening 
asphyxia from involvement of the muscles of the throat and 
chest, constipation, retention of urine, electric shocks from the 
brain to different parts of the body, and many others, has 
always been considered our most promising remedy. In the 
hands of physicians of the dominant school strychnia, given in 
doses as large as one-sixteenth of a grain every two hours, has 
been successfully used, although it is not at present strongly 
recommended by their highest authorities. In the practice of 
homoeopathic physicians, low dilutions of Nux have been useful. 
The higher attenuations also have yielded good results. Thus, 
Conant (N. E. M. Gaz., 1874) reports a cure with the 30th att., 
and J. M. Selfridge (Pac. Coast Journ. Horn., June, 1895) a 
cure with the 200th; both cases, however, were "incipient" 



TETANUS. 301 

rather than fully developed.— Gelsemium was first recom- 
mended by E. M. Hale. J. Martin Kershaw ( Arndt's System of 
Medicine) advises its use when there is "stiffness of the jaws; 
pain and stiffness in the back of the neck; spasmodic sensation 
in the pharynx and oesophagus, with difficulty of swallowing; 
constrictive pain about the chest, -with difficulty of breathing; 
dilatation of the pupils; cramps in the legs; involuntary dis- 
charge of faeces and urine; convulsive action of the voluntary 
muscles." Kershaw reports a case cured by teaspoonful doses 
every hour of a solution of fifteen drops of the mother tincture 
in half a glass of water. — Angustura vera in many respects 
resembles nux vomica, and in its pathogenesy has symptoms 
which are exceedingly suggestive of tetanus, including trismus, 
opisthotonos, stiffness in the neck and between the shoulder 
blades, jerking like electric shocks, tetanic spasms, caused by 
contact, drinking, etc. Hubbard (Med. Invest., Vol. 7) reports 
a cure of traumatic tetanus, in the early stage, from pins run 
into the foot, by the use of the 3d att., every half hour. B. 
L. B. Bayliss reports two cures made with the 2C0th att.— 
Cicuta is indicated in tetanic convulsions with rigidity of 
the entire body, marked opisthotonos, great embarrassment of 
respiration, spasms brought on by the slightest jar, sudden 
rigidity, followed by jerkings and violent contortions, and 
utter prostration. Dr. Beckwith reports a case cured by Cicuta 
3d att. — Hypericum is held in high regard in cases of nerve- 
traumatism, where there is excessive soreness and painfulness 
of the injured parts; it has been prescribed in tetanus resulting 
from penetrating wounds made by pointed instruments. In 
the case reported by W. F. Hocking, resulting from a dozen pins 
penetrating the sole of the right bare foot, pain ran up the 
right limb through the spine to the neck and face. The muscles 
of the neck and jaw became very rigid, mostly on the right side; 
also those of the thorax and abdomen.— Lachesis. Cures have 
been reported by J. Heber Smith (rigors, shooting pains in the 
back, opisthotonos, then trismus; remission from midnight 
until noon; after midnight, profuse sweat and agitated sleep; 
throat sensitive to contact, swallowing painful) and by M. L. 
Sircar (Horn. World).— Physostigma acts powerfully upon the 
spinal cord, producing tetanic spasms. "Paralysis preceded by 
twitching or trembling of the muscles; dilatation of the pupils; 



302. SPECIFIC INFECTIOUS DISEASES. 

syncope or tendency to fainting; trembling, convulsive action 
of the respiratory muscles, alternate dilatation and contraction 
of the pupils, the former corresponding with the period of 
spasm, and the latter with the period of quiescence." Wm. T. 
Helmuth reports a case cured with this remedy, a dose every 
two to three hours of a solution of ten drops of the tincture in 
a half a glass of water. "The spasms of the muscles of the jaw 
were so violent that a breath of air caused by^ a person passing 
would induce them." — Hydrocyanic acid is recommended by 
Hughes where there is cj^anotic appearance, coldness; the heart 
beats slower and slower, until it almost ceases, then suddenly 
rises in frequency with each return of the paroxysm. There is 
violent constriction of the diaphragm, with great difficulty of 
breathing. The spasms come on with lightning-like quickness. 
Opisthotonos. 

Among other remedies, likety to prove useful, mention should 
be made of Belladonna, Passiflora (used in teaspoonful doses 
of a fresh infusion or, if that cannot be obtained, of a fresh non- 
alcoholic tincture), Rhus toxicodendron (from getting wet?), 
Curare, Aconite, Cannabis Indica, Hyoscyamus and Stra- 
monium. 

It is probable that the most reliable remedies, homoeopath- 
ically, are Nux, Strychnia, Ignatia, Angustura, Physostigma 
and Gelsemtum. 

I would also suggest the use per rectum of an infusion of leaf- 
tobacco, thoroughly steeped. Tobacco acts powerfully upon 
the nervous system, possesses wonderful relaxing properties, 
and, as an injection, has been successfully used in the treatment 
of lockjaw by hunters and woodmen in Northern Europe. 



LEPROSY. 

Leprosy, lepra Arabum, elephantiasis Graecorum, is a chronic 
infectious disease, due to infection with the bacillus leprae. It 
is characterized by the presence of dark, brownish or reddish 
patches upon the skin or of flat diffuse nodules in the skin and 
mucous membrane, which undergo desquamation and ulcera- 
tion, and associated with a peripheral neuritis with fryperaes- 
thesia, anaesthesia and trophic changes. 



LEPROSY. 303 

Leprosy occurs endemically in nearly all parts of the world, 
seemingly independent of local conditions. In this country it 
is chiefly found in Mexico and in the Gulf states, on the Pacific 
coast, principally among the Chinese, in the Northwestern 
States among immigrants from Iceland and Norway. It is 
quite common in the West Indies, on the Sandwich Islands, and 
in India. The disease was first carefully studied by Boeck, of 
Christiana. 

The aetiology is not clear. A certain hereditary predisposition 
seems to exist in many instances, but persons whose ancestry 
have at no time shown a trace of the affection have acquired 
leprosy. The presence, invariably, of the bacillus leprae has 
been clearly demonstrated (Hansen and Neiser). It is rod- 
shaped, in length equal to one-third or one-half the diameter of 
a red blood globule, occurs in short rows or bundles, chiefly in 
the cells, also in the lymph spaces. Just how infection takes 
place is not understood, neither has the question of the possible 
contagiousness of leprosy been settled. Persons have for years 
held the closest possible relations to lepers without contracting 
the disease, as the relation of husband and wife or nurse and 
patient. Prof. Baetz, of Tokio, Japan, is authority for the 
statement that the people there, especially the peasants, sleep 
together, naked, under one cover, and that no case of contagion 
has been observed in spite of the fact that many of them are 
lepers suffering from ulceration. Arning performed inoculation 
successfully in a Hawaiian convict, but the assumption that 
leprosy may be transmitted by vaccination is rendered doubt- 
ful by experiences had in Japan. It has been suggested that in 
a majority of cases the disease, like syphilis, is transmitted by 
sexual intercourse; observation, especially on the Hawaiian 
Islands, gives some color to this presumption. 

Morbid Anatomy.— The lepra nodule or tubercle consists of 
granulation tissue (Virchow), the characteristic leprosy cell 
being larger than that of lupus, and more persistent; it runs a 
very slow course, finally undergoing absorption or degenera- 
tion. The new tissue is situated in the corium, at varying 
depth, and by extension into the connective tissue gives rise to 
leprous cellular infiltration. Thus nodular growths appear in 
the skin, with surrounding areas of ulceration and cicatriza- 
tion; the mucous membrane (conjunctiva, cornea, larynx) may 



304 SPECIFIC INFECTIOUS DISEASES. 

also be invaded. A peripheral neuritis is a frequent feature, 
with infiltration of cells, usually leading to fatty degeneration 
or atrophy of the primitive nerve fibres. This explains the ex- 
istence of various sensory derangements and their occasional 
unexpected disappearance, the result of absorption of the in- 
flammatory products; also the irregular anatomical distribu- 
tion of the affected regions. In quite recent investigations, ac- 
cording to Kaposi, "focal cellular infiltrations of the connective 
tissue framework, with secondary atrophy of the parenchyma- 
tous tissue, have been found in the lungs, intestines, testicles, 
liver, spleen, and kidneys." 

Clinical Forms. — The forms usually described are the nodular 
or tubercular and the anaesthetic. Each possesses distinctive 
features, but nearly all advanced cases present all the types 
mixed. The so-called macular leprosy consists of patches, 
dark-red or brownish in color, with or without infiltration, or 
spots of dark pigmentation, intermingled with non-pigmented 
spots, giving the subject a blotched, dappled appearance; or 
the pigmentation may disappear, leaving the skin snowy white. 
This form almost always passes into the nodular form. 

Nodular leprosy begins with the appearance of irregularly 
scattered dusky patches, i. e., maculae, sometimes infiltrated, 
and usually sore to touch, which maj^ continue for several 
months or years before the nodular growths show themselves. 
These growths, when they appear, are of dusky color, firmly elas- 
tic to the touch, from the size of a pea to that of a hazel-nut, 
widely and irregularly scattered or forming placques. Usually 
they are most numerous on the face, forming heav}* ridges 
above the eye-brows, thickening the lips, disfiguring the lobes 
of the ear, and giving to the face a low, coarse, stupid expres- 
sion. The epidermis covering the nodules often desquamates. 
The accompanying infiltration on other parts causes inconve- 
nience and even suffering. Papules may be found upon the con- 
junctiva and cornea, and may eventually lead to blindness. The 
nodules run a slow course. Some gradually disappear by ab- 
sorption, others break down, forming flat, irregular ulcers, 
which may involve deep tissues and then result in the destruc- 
tion of bones, loss of metatarsals, phalanges, and of entire 
joints. Involvement of the mucous membrane of the mouth and 
throat results in thickening and Assuring of the tongue, partial 



LEPROSY. 305 

destruction of the epiglottis, harshness of the voice and aphonia, 
with occasionally serious and even fatal complications. 

Loss of hair on the face, sickening sweetish odor from the 
mouth, anaesthesia of different parts of the body, and some- 
times fever, occur in the course of the disease, as well as such 
complications (erysipelas or lymphangitis) as may arise from 
extensive ulcerations and cachexia. In aggravated cases, run- 
ning an exceptionally acute course, cerebral symptoms, diar- 
rhoea, pneumonia or pleurisy may be present, with tendency 
to an early fatal termination. If the disease runs the usual 
chronic course, death takes place in from eight to ten years 
from marasmus or from some complication of the kidneys, lung 
or pleura. 

Anaesthetic Leprosy. — The characteristic feature of this form 
is anaesthesia, commonly preceded by redness of the parts and 
hyperaesthesia. It may occur in parts which are wholly nor- 
mal in appearance, or at the site of maculae or nodular growths, 
or in parts which have been the seat of pemphigus, an affection 
which on resolution leaves white shining anaesthetic spots or is 
followed by ulceration. The anaesthesia, though not usually 
affecting the deep parts, is complete, so that a burn or other in- 
jury may be inflicted without being felt by the person hurt. The 
writer is familiar with a case in which the existence of leprosy 
was first betrayed by the absence of pain from a severe burn on 
the fingers caused by removing a very hot chimney from a 
lighted lamp. Atrophy of the skin and deeper tissues develops 
after a time. The skin becomes wrinkled, flabby; the eyelids 
droop; the lower lip becomes pendulous, and there is constant 
escape of saliva from the mouth; deformities of the face, limbs, 
and especially of the hands, result from the partial and irregu- 
larly distributed paralysis of muscles or groups of muscles; the 
fingers assume a club-like shape, with "cap-shaped"nails; the 
hands turn inward at the wrist, and leprous baldness (lepra 
alopecia) sets in. More pronounced structural changes occur, 
trophic in character, as ulceration, sudden loss of small mem- 
bers, fingers and toes, or of hand or foot, i. e., lepra mutilans. 
Simultaneously a gradual lowering of the bodily temperature 
takes place, the patient becomes dull, apathetic, childish, and 
death from complications (pneumonia, albuminuria, diarrhoea, 
pyaemia, sometimes tetanus) closes the scene after a period of 
from fifteen to eighteen years. 
20 



306 SPECIFIC INFECTIOUS DISEASES. 

As already stated, the macular form almost invariably after 
a time becomes nodular, and anaesthesia, with the ulcerative 
lesions described, is a part of the nodular or tubercular form, 
so that a case in the late stage of the disease presents the 
symptoms of all the types. In addition, complications very 
often occur, such as scabies, flavus, general eczema, elephan- 
tiasis Arabum, etc. 

The diagnosis, if thcdisease is at all advanced, presents no 
difficulty. In the early stage a mistake may be made, especially 
as to the possibility of syphilis, but the lack of success under 
specific treatment and knowledge of former residence in a coun- 
try where leprosy is endemic, will settle the diagnosis. 

The prognosis is wholly unfavorable. 

Treatment.— There is no proof that any measures yet pro- 
posed are of the slightest value, save in so far as proper hy- 
giene, an out-of-door life, and due attention, usually surgical, 
to arising complications will prolong life and render it more 
comfortable. Chaulmoogra oil, in two-drachm doses, and 
Gurjun oil, in five- to ten-minim doses, are recommended by 
Osier, without comment. Carreau gave from 150 to 300 
grains daily, for three consecutive days, of chlorate of potash, 
producing "grave S3^mptoms of poisoning, but after the disap- 
pearance of these symptoms the leprous tubercles almost 
wholly disappeared, leaving the skin soft and wrinkled." 

Arsenicum album, Arsenicum iodatum, Iodine and Phos- 
phorus, possibly Lachesis and Psorinum, should receive a 
thorough trial. 



GLANDERS. 

Glanders or farcy is an infectious disease of horses, nearly al- 
ways fatal, which may be communicated from horse to man, 
at times from man to man. It is characterized by granuloma- 
tous formations in the nares (glanders) or beneath the skin 
(farcy), and caused by the presence of the bacillus mallei 
(Lceffler, Schuetz, 1882), an immobile bacillus, in appearance 
resembling the tubercle bacillus, but shorter and readily colored 
with alkaline analine d3^es. 



GLANDERS. 307 

Infection occurs chiefly among persons brought into close 
contact with horses; hence the disease is oftenest seen among 
veterinary surgeons, coachmen, and stock farmers. It results 
from direct contact with the poison and from inoculation on 
abraded surfaces. Owing to the volatile character of the 
poison, sleeping in a barn occupied by an infected animal is dan- 
gerous. Occasionally the poisonous discharges of a glandered 
horse are deposited upon the respiratory mucous membrane of 
a person riding behind it, by sneezing, snorting or coughing on 
part of the animal. 

The period of incubation varies from three to five days; ex- 
ceptionally it covers several weeks. The symptoms are those 
of local or general infection. Local infection is characterized 
by inflammation, lymphangitis and suppurative processes, 
often metastatic, terminating favorably by sloughing off, 
fatally by pyaemia. General infection, in the majority of cases 
secondary to local infection, is shown by symptoms of blood- 
poisoning, including the formation of pustules, furuncles and 
abscesses, and frequently involvement of the nasal mucous 
membrane, with fatal termination in a few days, or assuming 
a chronic form, with recovery in exceptional cases, but more 
often death from marasmus. 

The term glanders is applied to that form of the disease in 
which the nasal mucous membrane is severely affected. It be- 
gins with moderate fever, redness, swelling and lymphangitis 
at the seat of the infection. In a short time there is redness and 
great swelling of the nose, almost erysipelatous; nodules form, 
which are accompanied with ulceration and muco-purulent dis- 
charges, with a tendency, in many cases, to necrosis. Nodules 
also appear on the face and about the joints; these at first are 
hard and red, then soften in the centre, and discharge thick, 
fetid pus, the eruption closely resembling that of small-pox. 
These nodules form large suppurating tumors, resulting in ex- 
tensive and deep ulcerations. The lymphatics, especially about 
the neck, are enlarged, and there is in many cases a tendency to 
subacute pneumonia. The acute form is fatal within four to 
fourteen days. When the disease runs a chronic course, it is not 
always easily recognized; it frequently resembles coryza; re- 
covery takes place in exceptional cases only. 

By the term "farcy" is meant that form in which the infection 



308 SPECIFIC INFECTIOUS DISEASES. 

is manifested chiefly upon the skin, there giving rise to intense 
phlegmonous inflammation. The lymphatic glands are affected 
early, vague rheumatic pains are felt, and large nodular en- 
largements, i. e., farcy-buds, form. These soften, constituting 
extensive abscesses and giving rise to deep ulceration. Quite 
often the muscles become the seat of deep abscesses. In this 
form the nose is rarely, if ever, affected, neither are there any 
superficial skin symptoms. The general drift of the constitu- 
tional symptoms is that of a violent acute infection with rap- 
idly developing blood-poisoning. These symptoms may appear 
in a less violent form, running a chronic course, without exten- 
sive involvement of the lymphatics. In the acute type death 
results in from ten to twenty days. The course of the chronic 
form is indefinite; recovery may take place, but oftener an in- 
tercurrent attack of acute glanders, or finally marasmus, 
brings the case to a fatal issue. 

Examination after death shows the existence of numerous 
centres of purulent inflammation in the skin, nasal mucous 
membrane, pharynx, larynx, bronchi and pulmonary tissue, and 
alterations of the deeper organs, muscles and vascular system. 

The diagnosis rests upon the occupation of the patient, the 
character of the nasal discharges, of the eruption of the skin 
(farcy-buds), and the presence of the bacillus mallei. The ac- 
tion of mercurials and of the iodide of potassium, with the his- 
tory of the case, will determine whether the case is one of 
syphilis or glanders. Tuberculosis does not especially affect 
the nose and skin, while it does by preference affect the lung 
and the organs of speech. The eruption of variola is much more 
uniform than that of glanders, does not appear in successive 
crops, and has not the deep and extensive ulceration of 
glanders. 

The prognosis is exceedingly unfavorable in acute cases; it is 
serious in chronic cases, but recoveries are made, although 
usually these are not perfect. 

Treatment. — Proplrylaxis includes the prompt killing of all 
infected animals, proper care of the carcass by deep burial or 
cremation, and the destruction of eve^thing about the stable 
which has been exposed to the infection, as litter and fodder, 
with thorough disinfection of stall and barn, and their con- 
tents. It is evident that extreme care is necessary in handling 
a diseased animal. 



GLANDERS. 309 

Hell, and others, claim to have had good results from the in- 
jection of sterilized blood serum of horses which had just passed 
through an attack of glanders, and they have used this treat- 
ment for prophylaxis and cure of the disease. 

Infection having taken place, surgical measures must be 
promptly employed, as the actual cautery or strong carbolic 
acid at the seat of the infection, or excision of the infected 
parts. Vigorous antiseptic treatment must be maintained at 
any point presenting evidence of local infection. "Farcy buds" 
are to be opened early and freely, and the strength of the pa- 
tient must be kept up by nutritious diet, including the use of 
stimulants when indicated by the general condition. 

Mallein has been the subject of extensive experimentation by 
Foth, Schuetz, Hutyra and Preiz, Bonome, and others. Chenot 
and Picq (1892) claim "to have cured glanders in guinea pigs 
by injections of blood serum from the ox. Guinea pigs treated 
with ox-serum, either before or after infection, recovered in 
seven cases out of ten. When inoculated with very violent cul- 
tures, which usually killed these animals in five days, the ani- 
mals are said to have survived from twenty-one to forty-two 
days." "Bonome reports that he has had favorable results in 
the treatment of chronic glanders in man by doses of y 1 ^ to -£$ 
C. C. The first dose is said to have caused an elevation of 
temperature, headache, polyuria, etc., but upon repeating the 
dose after two or three days a decided improvement of the gen- 
eral symptoms followed" (Sternberg: Immunity and Serum 
Therapy). 

Kali bichromicum has been urged by Hughes as thoroughly 
homoeopathic to glanders, and a careful study of its symptoms, 
of the respiratory organs and of the skin, substantiates the 
claim. Moore, an English veterinary surgeon, has used the 
remedy successfully. — Mercurius corrosivus is suggested by 
the violence of existing symptoms, and deserves a careful trial. 
— Arsenicum, also, should be useful in many cases. — Graphites 
should be of value in the chronic form; E. C. Price has used it 
successfully in horses. — Lachesis and Crotalus have symp- 
toms which may render them curative in glanders, but the in- 
sufficiency of clinical data makes it impossible at present to 
form reliable conclusions. 



310 SPECIFIC INFECTIOUS DISEASES. 



ACTINOMYCOSIS. 

An infectious disease of cattle, rarely of man, caused by the 
presence of actinomyces or ray-fungus, which sets up a chronic 
inflammation, with liability to metastasis to different organs, 
and symptoms of pyaemia and marasmus. 

The parasite (Israel, 1877; Ponfick, 1879,) is found in the pus 
which is discharged from the affected parts, and often occurs in 
masses large enough to be seen with the naked eye. The latter 
"consists of a conglomeration of innumerable threads of 
mycelia about a central mass of the same structure, from which 
the threads radiate in every direction to construct the ray 
shape. The mycelia can always be recognized by their clubbed 
extremities, and the mass, on an average about one-fortieth of 
an inch, is as large at times as one- tenth of an inch in diame- 
ter." (Whittaker.) 

In animals the affection consitutes a granulation tumor, and 
is practically a local disease; in man it sets up suppurative pro- 
cesses, with tendency to metastasis and sjmiptoms of severe 
constitutional involvement. The parasite usually finds entrance 
through the food taken (vegetables, especially barley); it read- 
ily lodges in the cavities of decaying teeth or upon abraded 
surfaces in the mouth or throat, and sometimes enters the 
bronchial tubes. A small granulation tumor is formed, soon 
followed by remarkable proliferation of the surrounding con- 
nective tissue, and eventually by suppurative processes. The 
constitutional symptoms which accompany the disease are: 
fever of an irregular type, considerable prostration, cough, and 
sepsis. 

Distinct forms are described, affecting the alimentary canal, 
the lungs, the skin, and the brain. In the alimentary canal 
the affection may be primary or secondary. Whitish patches 
are observed on the intestinal mucous membrane, covered 
with yellowish granulations and firmly adhering to the mem- 
brane upon which they rest. Swelling and subsequent suppur- 
ation with, often, discharge of contents into the peritoneal sac, 
frequently result; fragments are occasionally carried to the 



ACTINOMYCOSIS. 311 

liver, setting tip similar processes there. At times there is ag- 
glutination to the surface of the abdomen, with subsequent free 
discharge. The jaws are occasionally involved in man, the en- 
largement being great and resembling sarcoma; in several cases 
small growths have been found in the tongue. Pulmonary acti- 
nomycosis occurs as a bronchitis, closely resembling fetid bron- 
chitis; the expectoration of actinomycosis separates into two 
layers, the lower and turbid layer containing the parasite. The 
symptoms may resemble those of tuberculosis, with cough, loss 
of flesh and strength, hectic fever and night-sweats. If the 
case progresses rapidly, a broncho-pneumonia may be present, 
with characteristic expectoration, dullness on percussion, bron- 
chial breathing, and formation of abscesses and cavities. 
Metastasis occurs here to the liver, kidneys, intestines, heart 
or brain, or subcutaneous abscesses may form, or there may be 
necrosis of bony structure, as of the sternum or vertebras. On 
he skin the affection is seen chiefly on the cheek, angle of thet 
lower jaw, abdomen and groin; diffuse, tense infiltrations ap- 
pear, which involve the subcutaneous cellular tissue, forming 
small suppurating growths and abscesses with sinuous canals. 
This form is intensely chronic. Cerebral actinomycosis is ex- 
ceedingly rare, Bollinger having reported only one case in 
which the affection seemed to be primary; symptoms of cerebral 
tumor -were present. 

Diagnosis. — The disease so closely resembles chronic pyaemia 
that a differential diagnosis is extremely difficult. In actino- 
mycosis, however, the trouble is more of a local character, with 
pronounced tendency to destruction of tissue. As compared 
with tuberculosis, its preference for the lateral and posterior 
portions of the lungs, rather than the apices, is an important 
consideration. In the intestinal form it is often possible to de- 
tect by the "feel" nodular masses beneath the surface. The 
microscope alone can firmly establish the diagnosis. 

Treatment. — The treatment is surgical. Abscesses must be 
opened, the parts thoroughly irrigated, and all diseased tissue 
removed. Destruction of the diseased tissue with the solid stick 
of nitrate of silver has been practiced. Billroth has used tuber- 
culin successfully. "Gautier reports the cure of a case by the 
electro-chemical treatment, i. e., by the hypodermatic injection 
of a ten-per-cent. solution of potassium iodide into the dead 



312 SPECIFIC INFECTIOUS DISEASES. 

tissue, followed by the insertion of needle electrodes through 
which was passed a current of fifty milliamperes for twenty 
minutes." Oestertag calls attention to the value of iodine, as 
first advised by Thomassen, in 1885. The tumors are first 
cross-cut, and then treated with the tincture of iodine, while 
potassium iodide is exhibited internally. In cattle this treat- 
ment has proved of genuine merit and is even pronounced spe- 
cific by eminent authorities. In man, however, the disease as- 
sumes a more serious and diversified aspect and evidently re- 
quires different methods of treatment. Clinical experience so 
far is limited and not conclusive. The most promising remedies 
are Tuberculinum, Arsenicum album, Arsenicum iodatum, 
Silica, Phosphorus and Iodine. 



FEBRICULA. 

A fever of slight duration, not associated with any definite 
lesion or infection, running a rapid course toward a favorable 
termination. The term "ephemeral fever" is applied to a case 
of not more than twenty-four hours' duration; if the fever per- 
sists longer, it is a "febricula." 

./Etiology.— The causes cannot always be recognized. In fact, 
febricula, Weil's disease, Milk sickness, Malta fever, Mountain 
fever and Miliary fever are by recent writers, as a matter of 
expediency, classed as "infectious diseases of doubtful origin." 
The more common causes of febricula are abortive cases of 
probable infection occurring during epidemics of typhoid fever, 
scarlatina, measles, and other infectious diseases; slight gastric 
or gastro-intestinal disorders, frequently accompanied with 
nausea, vomiting or diarrhoea; intestinal irritation from the 
presence of parasites in the alimentary canal; abortive tonsillitis 
or pneumonia; mental excitement; transient, but severe, ex- 
posure to cold, heat, or fatigue; exposure to foul odors in per- 
sons very susceptible to them or to sewer gas; inflammatory 
conditions so slight as to be recognized with difficulty. 

Symptoms. — The onset may be abrupt, or there may be 
premonitory symptoms, as general indisposition, headache, 
nausea and vomiting. The fever usually develops rapidly, reach- 



FEBRICUEA. 313 

ing a temperature of 101° to 103°, or more, and there are noted 
the common signs of pyrexia, i. e., flushed face, rapid pulse, 
thirst, scanty and high-colored urine, fever-blisters on the lips, 
and a degree of nervous excitement which depends chiefly upon 
the age and temperament of the patient. In children it is by no 
means uncommon to find very great restlessness, symptoms of 
cerebral excitement and delirium, especially at night. In many 
cases bronchial irritation with cough is also present. 

The attack usually terminates by crisis in a few days; occa- 
sionally, however, a much longer period, sometimes weeks, 
passes before recovery takes place. If the latter is the case, re- 
missions often occur, and a condition may develop which sug- 
gests the possibility of malarious infection. 

Diagnosis.— The diagnosis cannot be made at the beginning 
of the attack; in fact, it depends entirely upon negative evi- 
dence, as the absence of inflammatory action and of infection. 
Sudden and complete termination of the case confirms the diag- 
nosis. 

Treatment consists of rest in bed, a light diet, an abundance 
of cool, fresh water, and attention to the stomach and bowels. 

Aconite. High fever; dry heat; quick, firm pulse; great rest- 
lessness, with energetic tumbling about in bed; great thirst; 
from cold; mental excitement or fright.— Gelsemium. Quick 
but soft and large pulse; face flushed, bright-red; hot, moist 
skin; dull headache, with dizziness; remissions.— -Bryonia. 
Fairly high fever; soreness all over; rheumatic pains, worse 
from moving about; bronchial irritation, with dry cough and 
soreness in the chest; tongue coated whitish-yellow; bitter, 
nauseating taste in the mouth; pain in the chest and epigas- 
trium; dull, stupefying headache. — Belladonna. Severe head- 
ache; heat in the head; the face and eyes are congested; pulse 
rapid and full; cerebral excitement; nightly and characteristic 
delirium; tendency to convulsions; sore throat. — Baptisia. 
Pulse rapid, full, soft; great thirst; tongue coated yellowish- 
white or brownish; bitter taste in the mouth; sweating; symp- 
toms pointing toward gastric fever. — Cina. High fever and 
thirst; jerking and twitching; foul breath; urine dark, high- 
colored; worms. — Rhus, Arsenic, EupaTor. perfol. ("bilious" 
fever, malarial symptoms), Ipecacuanha, Mercury, and pos- 
sibly Veratrum yiride, may also be indicated. 



314 SPECIFIC INFECTIOUS DISEASES. 



WEIL'S DISEASE. 

Under this name are grouped by common consent a set of 
symptoms first described by Weil, in 1886, of which jaundice, 
enlarged spleen and nephritis are the most prominent; the term 
"acute infectious jaundice" is also used. 

The cases described have usually occurred among men, from 
the twenty-fifth to the fortieth year, in the summer months, 
and seem to have resulted from exposure to the action of some 
decaj'ing substance. In the majority of cases the termination 
was favorable. 

Freyham reports the following as a typical case: "A man, 
aged thirty-two years, was suddenly seized with shivering, 
fever, headache, followed by semi-coma. On the next day 
jaundice was noticed. On admission, the tongue was dry and 
coated, the temperature 38.9° C, and the pulse 100. The urine 
was dark in color, contained bile pigment and a trace of albu- 
min, some hyaline casts, and a few red and white cells. The 
liver and spleen were both enlarged. The stools were loose 
and passed unconsciously. The fever terminated by lysis in a 
few days, the other symptoms disappearing at the same time. 
Severe pains in the calves were noticed, especially at this time." 
The jaundice usually occurs early, with enlargement and ten- 
derness of the liver, pale, colorless stools, enlargement of the 
spleen, and generally fall of both temperature and pulse. The 
temperature rarely rises above 105°, and begins to drop after 
the fifth or eighth day, reaching normal from the tenth to the 
twelfth day. Eruptions of the skin — erythematous, roseolar, 
or herpetic — sometimes with itching, frequently appear about 
the seventh day; there may be bronchial irritation, with cough, 
sore throat and epistaxis. 

In some cases, about one-fourth, a slight relapse takes place 
within a week after the return to a normal temperature, but it 
rarely lasts more than four or five days. Convalescence is slow 
and covers a period of many weeks. 

The prognosis is favorable. 

Jaeger, of Stuttgart, Germany, studied ten cases of Weil's 



MOUNTAIN FEVER. 315 

disease, of which three died. The latter, after death, presented 
" jaundice, fatty degeneration of the liver, with interstitial 
small-celled infiltration; acute parenchymatous nephritis, with 
fatty degeneration and cellular infiltration; haemorrhages into 
various organs; and enlargement of the spleen." Of these ten 
patients, seven gave a history of having bathed in a river 
which was found to be defiled; it was proved that in a village 
bordering on a tributary stream an epidemic disease prevailed 
among the fowl. Two of the patients had eaten food suspected 
of having been contaminated. One patient, the only woman 
in the series, thought she had "taken cold." Jaeger succeeded 
in isolating from the urine of most of the cases during life, and 
from the tissues of two of the fatal cases, an organism which, 
when inoculated upon lower animals, caused lesions analogous 
to those found in man, and from these again the same organ- 
ism could be isolated. Examination of the fowls above referred 
to "revealed the existence of lesions similar to those encoun- 
tered in cases of Weil's disease, together with the presence of 
organisms found in the cases in man, and which again, by inoc- 
ulation, could be transmitted to other animals, producing in 
turn characteristic lesions." This organism is described as a 
short rod, resembling the coccus, slightly curved, motile, with- 
out spores. "It grows in various culture media, to which it 
usually imparts a greenish fluorescence, sometimes causing 
liquefaction, at others not. It can be stained by first treating 
it with Kuehne's methylene blue, then briefly with dilute hydro- 
chloric acid, and finally with aniline oil." To this organism 
Jaeger applies the name "bacillus proteus fluorescens." 
The treatment is purely symptomatic. 



MOUNTAIN FEVER. 

The terms "mountain fever" and "mountain sickness" are 
used to cover groups of symptoms which really have little, if 
anything, in common, save that they occur in high elevations. 
Commonly, reference is had to a continuous fever which un- 
doubtedly is typhoid in character and tendency, and which 
after death presents the characteristic intestinal lesion of 



316 SPECIFIC INFECTIOUS DISEASES. 

typhoid. In others, as pointed out by Work, the symptoms are 
those of a simple continued fever, greatly varying in severity. 
Again, reference is had to those special symptoms which result 
from living at a high altitude, also from mountain-climbing, 
and here the term "mountain sickness" is especially applicable. 
These symptoms consist of headache, dizziness, nausea, rapid 
and irregular pulse, sense of choking and of fulness at the heart, 
embarrassment of respiration, and excessive bodily weariness. 
The former conditions find their remedy in rest, good nursing, 
and the use of Gelsemium, Baptisia, and similar remedies. 
The latter demands the exhibition of heart-stimulants, rest, 
and removal to a lower altitude. 



SWEATING SICKNESS. 

Sweating sickness or miliary fever is an acute disease of 
doubtful origin, occurring in epidemic form, characterized by 
fever, profuse sweating, and an eruption of miliary vesicles. 
The disease at one time was widely spread, but now seems con- 
fined to Italy and Picardy, France. The epidemics usually are 
of short duration, lasting from a fortnight to three or four 
weeks, and are remarkable for the swiftness with which they 
cover an invaded territory. Light cases present malaise, loss 
of appetite, headache, etc., followed by moderate fever, 
erythema, copious sweating, and an eruption of miliary vesi- 
cles. In severe cases there is high fever, great prostration, de- 
lirium, sometimes convulsions, and haemorrhage. 

During the middle ages sweating sickness assumed the pro- 
portions of a scourge, and its fatality was very great; more re- 
cent epidemics have proved comparatively light. The mor- 
tality is greatest during the earlier part of an epidemic. 



MALTA FEVER. 

A fever of doubtful origin and uncertain duration, with a 
tendency to relapse, affording a slight immunity from subse- 
quent attacks, endemic, and at times epidemic, seen in the island 
of Malta, Naples, and other districts at the Mediterranean. It 



MALTA FEVER. 317 

seems to be " a link between enteric fever and the so-called ma- 
larial marsh-fever." It is also known as Neapolitan fever, 
Mediterranean fever, rock fever. 

The British troops at Malta have at times suffered severely 
from it, but sanitary improvements have steadily lessened the 
frequency of epidemics, the severity of the symptoms, and the 
rate of mortality. It had been thought that infected food and 
drinking water might be aetiological factors, but special pre- 
cautions which were taken to correct both had no appreciable 
effect. 

For a long time the fever was considered of malarial origin, 
but failure to control the paroxysms with quinine has been 
deemed positive proof to the contrary. The observations of 
Bruce show that no characteristic typho-malarial lesions were 
present; infection of the spleen, with micrococci, was demon- 
strated by Bruce, Gipps, Hughes, and others. Enlargement of 
the mesenteric gland has been found by Italian observers. 

Hughes (London Lancet) "found the disease characterized 
clinically by a peculiarly irregular temperature curve, consisting 
of intermittent waves of pyrexia of a distinctly remittent type, 
each wave lasting from one to three weeks, with generally an 
apyrexial interval of two or three days. In rarer cases the re- 
missions may become so marked as to impart an almost inter- 
mittent character, but distinguishable clearly from the par- 
oxysms of ague. This pyrexial condition is usually very 
chronic, lasting even six months or more, and is not markedly 
affected by quinine or arsenic. It is usually accompanied by 
obstinate constipation, progressive anaemia and debility, and 
is followed, in a large number of cases, by very chronic rheu- 
matic and neuralgic complications, from which the patient may 
not recover for perhaps two years. The death-rate is very low, 
but the average stay in the hospital is from seventy to ninety 
days." 

Wescott (British Medical Journal) says: "The onset of the 
disease may be insidious or sudden, with fever of remittent 
type, simulating that of enteric fever; but the temperature soon 
becomes irregular, and, generally toward the end of the second 
week, the concomitant constitutional symptoms commence to 
disappear, the tongue cleans, the appetite returns, the mental 
condition improves, and convalescence appears about to set in, 



318 SPECIFIC INFECTIOUS DISEASES. 

but the temperature remains high, and at any moment the pa- 
tient is liable to suffer from a complication resembling rheu- 
matic fever; the joints swell and become painful, and the con- 
stitutional symptoms of fever return, but the characteristic 
perspiration of rheumatic fever is absent, and there is evidently 
no relation to it. This complication, like every symptom of the 
disease, is of the most uncertain duration and degree; it may 
attack only one or two joints, and last only a day or two, or 
it may cause permanent joint disease. Local paralysis occurs 
frequently. The extensor muscles of the feet are those almost 
exclusively affected." 

The duration of the disease is variable and the mortality 
light. Removal from an infected district does not materially 
lessen the severity of the attack or shorten the course of the 
fever. 

Treatment. — Treatment consists of good nursing, careful 
feeding with easily digested, liquid food, and, in protracted 
cases with much prostration, the moderate use of stimulants. 
The remedies are those applicable to the treatment of continu- 
ous fevers with rheumatic complications. 



MILK FEVER. 

Milk sickness or milk fever is a presumably infectious disease 
of cattle, also affecting young horses and sheep, which may be 
communicated to man by eating the meat or drinking the milk 
of diseased animals or by using butter and cheese obtained from 
the same source. It is stated that the affection -was frequent 
and very fatal when the country was first settled; now it is 
rare, but is still seen in North Carolina. The affected animal 
appears sick and exhausted, the eyes are injected, there is stag- 
gering and trembling after every muscular exertion (hence 
called "trembles"), and death occurs in convulsions. 

Dr. J. Howell Way, of Waynesville, N. C. (Amer. Jour, of the 
Med. Sciences), describes the disease as it occurs in man as fol- 
lows: "The onset is gradual and insidious; the patient becomes 
apathetic, and finds it impossible to arouse himself to his accus- 
tomed activity. Cephalalgia, anorexia, nausea, and marked 



MILK FEVER. 319 

thirst represent the early history of the disease. The tongue, 
at first covered with a white fur, becomes, after a few days, 
large, heavy, and flabby, the breath assuming a sweetish foul- 
ness comparable to the breath of an un weaned calf . Vomiting 
occurs frequently, and is attended with very little immediate re- 
lief. The fluid expelled from the stomach most frequently has 
a slightly bluish color, and is not, as a rule, very abundant in 
quantity, many of the efforts at emesis being unattended with 
the ejection of any fluid whatever. The emesis ceases late in 
the course of fatal cases from sheer exhaustion, hiccough being 
then a frequent source of suffering. The abdomen is flaccid, 
and peristaltic action seems to be suspended, although diar- 
rhoea is sometimes observed. Marked aortic pulsation may 
sometimes be felt through the abdominal parietes. The fre- 
quency of cardiac action is not increased, as a rule; in the 
earlier and middle periods of the disease it may be at times 
slowed, but in the profound prostration that ensues prior to 
death it is increased and labored, and the larger arteries seem 
to be unusually well filled. The temperature is generally sub- 
normal, ranging from 97° to 98° F. In grave or fatal cases the 
sufferer sinks into a comatose condition." 

The duration of the disease is variable; death may occur in 
two or three days, or the patient may linger for several weeks . 
No definite lesion has as yet been found. 



PARX II. 

CONSTITUTIONAL DISEASES. 



21 



PART II. 



CONSTITUTIONAL DISEASES. 



RHEUMATIC FEVER. 

Rheumatic fever or acute articular rheumatism is an acute 
febrile affection characterized by pain and inflammation of the 
fibrous tissue about the joints, with a tendency to involvement 
of the heart and other serious complications. Increasing sus- 
ceptibility to the disease follows each attack. 

^Etiology. — Climate.— Acute articular rheumatism occurs 
oftenest in temperate, humid climates, when the weather is 
changeable or damp and cold. Dry cold rarely develops rheu- 
matic affections; the season of the year in which it is most fre- 
quent are the months of February, March and April, in this 
country. Occupation. — Persons whose occupation involves 
much exposure are particularly liable to articular rheumatism; 
hence sailors, bakers, laborers, foundrymen and hack-drivers 
often suffer from it. Age. — Sucklings and very young chil- 
dren are rarely affected; young adults, from twenty to forty 
years of age, according to statistics gathered in England, furnish 
80 per cent, of the victims; according to Bell, nearly one-half of 
all the cases occur from the fifteenth to the twenty-fifth year. 
Liability grows less and less after the fortieth year has passed 
and almost ceases at fifty. Sex. — Among young persons, up 
to twenty years of age, girls suffer more than boys; after that 
age, men furnish by far the larger number of cases. 

Among the exciting causes may be mentioned exposure, sud- 
den chilling of the surface of the body, extraordinary fatigue, 
exertion involving especial strain upon joints already weakened 



324 CONSTITUTIONAL DISEASES. 

from previous attacks, or a fall, blow or injury in the neigh- 
borhood of joints. Habitual and free sweating is common 
with persons of a rheumatic tendency such as exists in some 
families. 

The specific cause of the disease is in doubt. The so-called 
"metabolic" theory assumes that a morbid material is pro- 
duced in the s\'stem, as the result of faulty assimilation. The 
"nervous" theory holds that the nerve centres are primarily 
affected by cold, and that the local symptoms are either 
trophic in character or due to the accumulation of lactic acid 
resulting from errors in metabolism depending upon disturb- 
ance in the nerve centres. Others maintain the existence of an 
infection or mycosis, and rest their belief upon the nature and 
course of the disease, its liability to occur in connection with 
scarlatina, puerperal fever, and other infectious diseases, and 
the almost specific action of salicylic acid, which is held to be 
a powerful antimycotic remedy. Failure to find a specific 
micro-organism in the blood or in the affected organs militates 
against this theory; furthermore, articular rheumatism is not 
transmitted from man to man, and the salicylic acid treatment 
often fails to accomplish what has been claimed for it. 

Morbid Anatomy. — The affected joints are hyperaemic and in- 
filtrated; there is swelling of the synovial membrane, with an 
increase of the synovial fluid, distending the articular cavity. 
This exudation may be normal, or acid, turbid, albuminous, 
containing leucocytes and even flakes of fibrin. Pus is rare in 
uncomplicated cases. The cartilages sometimes are slightly 
eroded. In tedious cases the periosteum of the articular sur- 
face and the marrow of the extremity of the bone show in- 
creased vascularity. These conditions develop and disappear 
quickly; involvement of the cartilaginous and bony structures 
has been observed later, and may persist long after the exter- 
nal signs of articular inflammation have ceased. 

Symptoms. — The onset usually is sudden; at times the pa- 
tient first complains of indisposition, irregular pains, sore 
throat, slight chilliness, and other symptoms of having taken 
cold. A sharp chill may set in , but usually there is merely a 
sense of coldness and shivering; in either case this is followed 
by fever and severe pain in one or more joints, the disease being 
practically established within two hours from the onset of the 
first symptom. 



RHEUMATIC FEVER. 325 

The fever presents no characteristic features. The tempera- 
ture rarely rises above 102°; the pulse is rapid, soft, and com- 
monly exceeds 100 beats per minute; the tongue is moist and 
covered with a white fur; anorexia, thirst, dark, high-colored, 
scanty urine, and other signs of pyrexia are present, with 
copious, sour sweat throughout the course of the disease. 

The joints most frequently attacked are the medium-sized 
joints, as the knees, ankles, wrists and elbows, often the 
shoulders. They generally become involved successively. It is 
exceptional to find only one joint affected. Corresponding 
joints are frequently attacked. Inhibition of motion is the first 
expression of articular involvement, and not infrequently it is 
noticed before the external signs, redness and swelling, are ob- 
served. The swelling is due to serous infiltration of the peri- 
articular tissues and usually is moderate, although in the knee 
it may attain considerable size. When the ankles and wrists 
are the seat of the inflammation, the infiltration may be quite 
extensive, including the sheaths of the tendons and giving rise 
to marked enlargement of the hands and feet. If the case is 
very severe, the articulations of the jaws, ribs, and the various 
symphises may be involved, and in exceptionally violent at- 
tacks arthritis of all the large joints may be seen. The verte- 
bral, stern o-clavicular and phalangeal articulations are much 
less liable to be affected here than in some other forms of rheu- 
matic arthritis, as in the gonorrhceal form. The swelling is 
most pronounced in the joints which lie near the surface; there 
may be pitting of the skin over such joints, from subcutaneous 
oedema; swelling and redness may not be noticeable when the 
deep, large joints are the seat of the inflammation. Heat is 
almost always present, and can usually be detected by the touch 
of the hands. Redness varies from a slight flush to a pronounced 
deep red, sometimes uniform, again appearing in streaks or 
stripes. The pain is very severe, the slightest motion causing 
intense suffering. It is felt early, and gives rise to persistent 
attempts on part of the patient to place the affected limb in a 
position to avoid all tension; aggravations occur at night, from 
pressure, from motion. A peculiar feature of the local disease 
is the tendency to successive but irregular involvement of differ- 
ent joints, with recurrence of the affection in articulations 
which had seemingly recovered. 



326 CONSTITUTIONAL DISEASES. 

Profuse, acid sweats, later often neutral or alkaline, are con- 
stant and constitute a source of much discomfort. These are 
not in any sense beneficial or critical, but arise from profound 
nervous disturbance. Sudaminal and miliary vesicles are fre- 
quent, and are largely the result of irritation of the skin from 
the excessive sweating. The temperature in cases of moderate 
severity averages from 102° to 104°; it rises and falls as the 
local S3 r mptoms increase or lessen in intensity, and is somewhat 
kept in check by the copious sweating. When hyperpyrexia 
exists, the thermometer rises to 110°, or higher, and severe ner- 
vous symptoms are present. Recovery is attended with a 
gradual lowering of the temperature. The pulse rarely exceeds 
100; if it reaches 120, complications usually exist. Murmurs 
at the apex of the heart are frequent and should be carefully 
watched. The urine is scanty, high-colored, acid, albuminous, 
and on cooling deposits urates; there is deficiency or absence of 
chlorides. The saliva frequently is acid in reaction. Haemor- 
rhages are occasionally seen; they generally depend upon pul- 
monary congestion or upon blood-changes; epistaxis is a fre- 
quent and unimportant symptom. The blood is altered rapidly, 
anaemia constituting a common and clinically important symp- 
tom. 

The mind is clear, save when there is hyperpyrexia. 

Nodules, of the size of a small shot or a pea, or larger, are 
often discovered under the scalp and on other parts of the 
body. They are not painful to the touch, and appear and dis- 
appear with remarkable rapidity. They exist also in the ten. 
dinous sheaths and on the periosteum, where they may be d <*_ 
tected by palpation. It is stated that their presence may b e 
regarded as a positive indication of rheumatism and that they 
are especially frequent in connection with chronic rheumatic 
endocarditis. 

Subacute articular rheumatism is characterized by the same 
symptoms in a milder form, with involvement of fewer joints, 
much less pain, more moderate fever, and a temperature rarely 
exceeding 100°. The course is tedious, often lasting for many 
weeks, even months, with a tendency to become chronic. The 
disease is frequent in children; heart-complications are com- 
mon. 

Complications.— Rheumatic affections of the heart (endocar- 



RHEUMATIC FEVER. 327 

ditis, pericarditis and myocarditis) are frequent. They do not 
depend upon the severity or extent of the local affection or 
upon the anatomical relation of the affected joint to the heart. 
The frequency of their occurrence is variously estimated, some 
authors stating that they are seen in nearly fifty per cent, of 
all cases of rheumatic arthritis— undoubtedly a rather large es- 
timate. Nevertheless, cardiac complications are common, espe- 
cially in children and young people; they grow less frequent in 
persons more advanced in life. Endocarditis usually appears 
during the second week of the rheumatic attack, sometimes 
later, and commonly affects the mitral segment. It is verru- 
cose, rarely ulcerative. Its chief danger lies in secondary struc- 
tural changes, leading to valvular disease. 

Pericarditis may occur in connection with, or independent of, 
endocarditis. Some authorities hold it to be the most common 
form of cardiac complications. It may be fibrinous, sero- 
fibrinous, or purulent. Pain in the precordial region, palpita- 
tion of the heart, and extreme difficulty of breathing, with 
great restlessness, anxiety and delirium, are present. The phys- 
ical signs are easily recognized. Myocarditis is infrequent, and 
usually is associated with inflammation of the endocardium 
and pericardium; its symptoms are those of progressive degen- 
eration of the heart-muscle and dilatation, with irregular, 
feeble, rapid pulse, palpitation, dyspnoea, and syncope. 

Cerebral complications occur in from three to five per cent, 
of the cases, and are usually the result of intense congestion, 
sometimes of toxaemia. The old-time belief that the brain 
symptoms arise from metastasis is no longer held. Frequently 
striking disturbances of the brain are seen in connection with 
cardiac complications, due to embolism or some other disturb- 
ance of the circulatory apparatus. Generally speaking, these 
disturbances occur in persons who have a natural tendency to 
brain-complications ("cerebral disposition"), or have through 
bad habits developed great weakness and irritability of the ner- 
vous system. Brain complications, as a rule, are seen in the 
severe cases only, and then between the fifth and twentieth 
day; they may appear suddenly as disturbances of vision, hal- 
lucinations, difficulty of speech, etc., attended with dizziness and 
alteration of the pupils, or may follow a sudden aggravation 
of symptoms, with severe headache, tendency to nightly de- 



328 CONSTITUTIONAL DISEASES. 

lirium, and noticeable elevation of the temperature. Delirium 
is constantly present; it may be low and muttering, but often, 
and nearly always in adults, is noisy and violent, especially 
when there is a considerable rise in the temperature. Convul- 
sions sometimes occur. Coma is common when there is hyper- 
pyrexia or uraemia, and must be considered an exceedingly 
grave symptom. Exceptionally coma sets in without previous 
delirium or convulsions; if so, the temperature is very high and 
the case almost sure to advance to a rapidly fatal termination. 

Chorea is not uncommon in the lighter attacks among chil- 
dren, and meningitis, especially in connection with ulcerative 
endocarditis, has been observed occasionally. 

Hyperpyrexia is in itself a serious complication, intimately 
associated, as it is, with the cerebral manifestations just de- 
scribed. The temperature may reach 110°, or more; the pulse 
is rapid and feeble; prostration is extreme, and there may be 
delirium and stupor. 

The cutaneous complications are varied. Sudamina and 
miliary eruptions are common. Erythema, urticaria, purpura, 
and a rash closely resembling that of scarlet fever are noticed 
in many cases. Pulmonary congestion may occur and often 
p roves rapidly fatal; pneumonia and pleurisy frequently com- 
plicate endocarditis and pericarditis. 

The course of the disease is somewhat erratic; in many cases 
the patient appears to do nicely, when the inflammation at- 
tacks an articulation heretofore not involved, or a complication 
may suddenly arise which changes the entire picture. 

The duration in light cases is from two to four weeks; more 
serious cases run from three to six weeks; others continue for 
several months. The affection has been considered self-limited, 
medication apparently having little or no power to shorten its 
duration or to materially modify its course. It is held by some 
that the salicylic acid treatment is almost specific and that in 
many cases it will reduce the duration of the fever to five or seven 
days. Clinical experience fails to make good this assertion and 
proves that relapses under the use of salicylic acid are very 
common, particularly so if the use of the drug has been discon- 
tinued a trifle too soon. 

Prognosis. — In uncomplicated cases the prognosis is good, 
not more than three per cent, of the cases terminating fatally. 



RHEUMATIC FEVER. 329 

Cardiac complications render the prognosis somewhat uncer- 
tain, not so much as to the immediate outcome of the case as to 
the eventual danger of organic disease of the heart. Cerebral 
rheumatism is always a dangerous complication. Patients 
who are somewhat advanced in life rarely make a perfect re- 
covery, but remain subject to chronic nervous disorders of 
a depressing character. 

Diagnosis. — The diagnosis is comparatively easy. Rheumatic 
fever rarely occurs during the first year of life, and the acute 
arthritis of infants, which it somewhat resembles, is recog- 
nized from its limitation, usually, to one joint, chiefly hip or 
knee, with a tendency to purulent effusion (gonorrhoeal oph- 
thalmia and vaginitis of the new-born). Acute osteo-myelitis 
or acute necrosis in the lower extremity of the femur or tibia 
have a much greater intensity of the local symptoms, involve 
the epiphyses rather than the joints, and are accompanied with 
much more serious constitutional disorders. Septic arthritis 
depends upon the existence of some infectious disease, as scarla- 
tina, typhoid, fever, erysipelas, syphilis, pyaemia, etc. Gout 
differs in its mode of onset and in its limitation to a single small 
joint; in case of an intercurrent attack of . rheumatism in a 
gouty patient the uric-acid test will determine the diagnosis. 

Treatment. — The suffering connected with articular rheuma- 
tism is so great that every possible effort must be made to 
afford relief. The bed of the patient should be as comfortable 
as circumstances will permit; not only should the mattress be 
soft and elastic, but the sheets and blankets must be kept per- 
fectly smooth. The excessive sweating demands the use of 
woollen blankets rather than cotton sheets; the former absorb 
the moisture, while the latter increase the "clammy" sensation 
which is a source of great discomfort; the danger of taking 
cold is also much reduced when woollen blankets are used. 
The night-gown must be changed often; hence the wisdom of 
having a number of flannel robes made, which can be changed 
with comparative ease if opened on the outer sleeves and along 
the entire front. To ease the pain in the inflamed joints, they 
should be kept at rest by the use of firmly adjusted porous 
splints, plaster-of-Paris casts, or by packing in sand-bags. 
Cloths wrung out of hot water, or chloroform liniment, or 
equal parts of the tincture of aconite root and chloroform, or, 



330 CONSTITUTIONAL DISEASES. 

in some cases, cold compresses, may be applied locally. Fuller's 
solution (carbonate of soda, six drachms; laudanum, one 
ounce; glycerine, one ounce; water, nine ounces),, applied by 
means of hot cloths, acts soothingly. Osier recommends Pa- 
quelin's thermo-cauter\r. Ichthyol, painted on the inflamed 
joint, covered with a coating of French chalk, the whole 
wrapped in cotton and renewed every twenty-four hours, is a 
recent favorite treatment. Friction is not kindly borne. 

The diet should be light and nutritious. Milk is excellent and 
may be diluted with some alkaline mineral water. Broths and 
soups must be given with discretion; meat and meat-extracts, 
as a general thing, are not desirable until convalescence is fully 
established. The patient should drink freely of fresh, pure 
water or of alkaline mineral waters; crust-coffee, barley-water 
or oat-meal gruel, diluted with milk and water, are both re- 
freshing and nourishing. The cold pack or sponging in cold 
water may become necessary during hyperpyrexia. "As a rule, 
it is better to place the patient in a bath at a temperature of 
90°, and gradually cool it down to 65°, or even 60°. The pa- 
tient should not be kept longer in the bath than the time it 
takes to reduce his temperature to 101° or 100°. As the tem- 
perature continues falling for some minutes after the removal 
from the bath, he should be rapidly dried and wrapped in blan- 
kets, and a stimulant may be necessary. It is seldom found 
necessary to keep the patient in the bath longer than one 
hour. In the majority of cases from one-half to three-quarters 
of a hour is not exceeded. If the reduction is not effected in an 
hour, there is no reason why the patient should not be kept in 
longer, as the measure is the only one that gives us any hope 
of doing good. In some instances a single bath is all that is 
necessary. If the temperature should, however, reascend, a 
second bath should be given. There is hardly a limit to the 
number that may be employed." (Hare's Therapeutics.) 

The treatment with salicylic acid is still held in high esteem 
by many. It is claimed that it gives relief from pain in five 
hours; that it lessens the swelling of the inflamed joints within 
twenty-four hours; and that it reduces the average duration of 
the disease to five days. (Whittaker.) The following is a 
favorite formula: Sod. salicyl., 2 drachms; glycerine, 1 ounce; 
peppermint water, 3 ounces. Give from a dessertspoonful to a 



RHEUMATIC FEVER. 331 

tablespoonful every two to four hours, discontinuing the medi- 
cine when toxic symptoms — nausea, headache, ringing in the 
ears, vertigo, etc. — appear. Others admit that under salicylic 
acid the pain is relieved, but deny that it cuts short the dura- 
tion of the disease or lessens the danger of cardiac complica- 
tions, and affirm that under its use relapses frequently occur. 
Potassium bicarbonate, given every few hours until the urine 
has become alkaline, then reduced, but continued in sufficiently 
large doses to maintain the alkalinity of the urine, is said to 
lessen the danger of heart-complications. Oil of wintergreen, 
twenty minims every two hours in milk, has many warm advo- 
cates. The administration of antipyrin, acetanilid, phenacetin, 
and allied drugs, has of late become fashionable, chiefly because 
they reduce fever and relieve pain, but their action upon the 
blood and their depressing effect upon the heart are very un- 
desirable. Acetanilid should be given in doses of 4 to 8 grs. 
three times daily; antipyrine in doses of from 10 to 20 grs. 
every two or three hours until relief is obtained; and phenace- 
tine in doses of from 5 to 15 grs. 

Aconite is beyond question of great value at the beginning 
of the attack. The pains are shooting, tearing, worse at night; 
the joints are red, swollen, and very sensitive. When used in 
the mot her- tincture of the fresh root, in half-drop doses every 
one to two hours, its effect often is surprising, promptly reduc- 
ing the temperature, fever, and pain. There is no reason why 
a dilution of this tincture in hot water should not be used 
locally. — Bryonia not only relieves the pain, but cuts short the 
attack. The inflamed joints are slightly swollen and of faintly 
reddish color, the redness often radiating outwards; sometimes 
the joint is badly swollen, with much heat and considerable 
redness. The pains are severe, stitching, tearing, shooting. 
There is shivering, coldness, fever, sour sweat. — Arnica has ex- 
cessive soreness all over and of all the joints on motion. The 
affected joints are pale and rose-tinted. Bruised pain about the 
region of the heart. Bruised, stitching, tearing pains. Epis- 
taxis of dark, fluid blood. "Great fear of being approached." — 
Belladonna has great dryness and heat of. the body, suscepti- 
ble to the touch; the affected joint is swollen bright-red, an 
area of redness extending around it; the pain is tearing, shoot- 
ing, lancinating. Cerebral rheumatism, with characteristic 



332 CONSTITUTIONAL DISEASES. 

delirium. General plethora. — Mercurius. The affected joints 
are swollen and pale; sore, sharp pains; jerking, wandering pains 
in the thighs, shoulders, arms. Pains worse at night, from 
the warmth of the bed. Profuse sweat, clammy, oily, sticky, 
often with cold hands and feet. Anaemia; subacute attacks. 
— Rhus toxicodendron. Particularly useful in muscular rheu- 
matism, it is also of service in the articular form after exposure 
to dampness, with general soreness, copious sweating, aggra- 
vations from attempts to move, redness of the affected joints, 
and shining, oedematous swelling; stitching pain of the parts 
when touched; great sensitiveness to cold. — Apis mellifica. 
Great soreness of the affected parts; the affected joints are of 
pale-red color and oedematous; burning, stinging pains; rheu- 
matic pain in the shoulder-blade; numbness; warmth of the 
body; sweating is accompanied with a sense of comfort and 
relief. — Caulophyllum. "Rheumatism in small joints, espe- 
cial^ of the hands, with cutting pains on closing the hands, 
especially in women with suppressed menses." (T. F. Allen.) 
Subacute form.— Ferrum phosphoricum. "Of the shoulders; 
the pains extend to the upper part of the chest; and of the 
hands, which are swollen and painful, or of the knee, with 
severe pain; or of the ankle, with shooting pain." (T. F. A.) 



CHRONIC ARTICULAR RHEUMATISM. 

An affection of late middle or advanced life. It is frequently 
seen among persons who are exposed to cold and damp, as 
laborers, washerwomen, etc. Less often it follows acute or 
subacute attacks. Anatomically it consists of injection of the 
synovial membrane, usually with slight effusion and thickening 
of the fibrous structure of the joint, which, interfering with its 
free play, causes more or less complete anchylosis; eventually 
there is atrophy of the muscles standing in anatomical rela- 
tion to the affected articulation, due to disuse, to nervous in- 
fluence, and to pressure on the muscles and vessels involved. 

The symptoms are chiefly stiffness and pain of the involved 
joints, with little, if any, swelling or redness. The pain is 
greatly increased by motion, change of -weather, overexertion, 



CHRONIC ARTICULAR RHEUMATISM. 333 

exposure to cold and damp. Usually the greatest amount of 
discomfort is felt from the first muscular effort made after a 
prolonged rest, such as a night's sleep; after stirring about for 
a time, the stiffness and soreness gradually grow less and dis- 
appear. In some cases the joint is sore to the touch. In the 
course of time anchylosis may develop, with more or less de- 
formity of the joint. 

The general health is not materially affected, save in cases 
where constant severe pain eventually weakens the system, 
followed by digestive disturbances, anaemia, and neuralgic 
affections, or in the more exceptional instances where valvular 
lesions of the heart complicate the case. 

The prognosis is bad so far as it refers to a cure, although 
under favorable circumstances even perfect recovery may take 
place. The disease does not materially shorten life except 
through its complications. 

Treatment.— Residence in a warm dry climate, free from 
sudden and great changes, is of supreme importance and, if 
within reach of the patient, must be insisted upon. The same 
applies to the house in which the patient lives; if damp, every 
effort to give relief will prove unavailing. Flannel must be 
worn next to the skin, and general health maintained by close 
attention to the details of sound hygiene. Massage and pas- 
sive motion should be practiced perse veringly; this treatment 
is mildly stimulating, improves nutrition, and lessens the im- 
mobility of the joint. If there is much pain, dry heat, per- 
sistently used, often proves of great benefit. Warm baths, 
taken at any of the hot sulphur springs, are usually helpful if 
used long enough and under the direction of a competent med- 
ical man. The temperature of these waters should range from 
96° to 114°. Hot mud-baths often afford relief promptly. 
America abounds in these springs. Arkansas, Canada and 
Michigan in the East, and New Mexico and Southern Cali- 
fornia in the West, and other States, offer every opportunity 
for testing the merit of this treatment. Old age, organic 
disease of the kidneys, especially when complicated with de- 
generative changes in the arteries or hypertrophy of the left 
ventricle, are counter-indications. 

Therapeutics. — It is often claimed that the administration 
of remedies for the relief of chronic articular rheumatism is 



334 CONSTITUTIONAL DISEASES. 

little more than a waste of time. This is not true. Excellent 
results often follow the persevering use of the indicated remedy. 
Calcarea carbonica is a remedy of far-reaching power when 
the disease occurs in patients of a leuco-phlegmatic tempera- 
ment suffering from malnutrition, tendency to clammy sweat- 
ing (especialhyof the feet), coldness of the feet, general catarrhal 
predisposition, and scrofulous troubles of the eye-lids and ears. 
The swelling of the joints is well pronounced and often is the 
effect of working in water. Aggravations from every change 
of weather; crackling crepitation in the affected joints; gouty 
nodosities about the small joints, especially about the fingers. 
There is much bodily weakness, particularly weariness of the 
limbs, rendering it difficult to go up stairs. Deficient powers of 
resistance. — Causticum. Rheumatism in the shoulder and 
articulation of the jaw. The joints feel stiff; the tendons are 
shortened, drawing the limb out of shape. Pain is tearing, 
stitching, piercing; worse in the evening, better in the morning; 
renders him restless and compels him to move about, without, 
however, getting relief from motion; worse from east wind and 
from dn^ cold weather, during snow storms; relief from warmth. 
Paralytic "weakness of the extremities; trembling weakness of 
the hands. Restlessness at night; he uncovers himself; gets up 
in the morning utterly despondent, but feels better as the day 
advances. Tendency to soreness and chafing in the folds of the 
skin. Weakness of the sphincter of the bladder. — Hepar sulph. 
calc. is indicated in scrofulous persons who sweat easily (sour 
perspiration), are anaemic, exceedingly sensitive to cold, and 
who have had "thorough" mercurial treatment. The affected 
joints are moderately swollen; there may be some redness and 
a sensation as if the joint had been sprained. Pains as though 
a splinter were sticking into the joint. — Lycopodium is useful in 
old people who suffer from malnutrition, are emaciated, melan- 
cholic, peevish. The hands especially are affected; the pain, 
which is tearing, grows worse during the day until evening, 
when relief is had. Its well-known dyspeptic symptoms often 
call attention to it; there is almost canine hunger, but as soon 
as he begins to eat the stomach feels full and distended, and he 
is obliged to stop. Gastric flatulency; atonic dyspepsia. He 
craves being in the open air, and often suffers from chronic 
eczema. — Sulphur. Sensitiveness to cold, wind, open air, 



MUSCULAR RHEUMATISM. 335 

change of weather; relief from heat; aggravation from wash- 
ing in cold water; burning heat of the feet. Scrofulous skin- 
troubles which occasionally get better, the improvement being 
followed by aggravation of the rheumatism. Mental irrita- 
bility. Rheumatic affection of the knee-joint. 

Bryonia, Pulsatilla, Rhus toxicodendron, Mercurius, 
Nux vomica, and others, are at times indicated by clear-cut 
constitutional characteristics. 



MUSCULAR RHEUMATISM. 

Muscular rheumatism, myalgia, or myodynia, usually affects 
single muscles or groups of muscles, chiefly the voluntary, but 
sometimes the involuntary muscles, as those of the oesophagus 
and bladder. The exact seat of the affection is not known, but 
probably all the tissues constituting a muscle are involved. 

The disease usually results from exposure to cold or sudden 
chilling by a draught of air, especially if only one side of the 
body is exposed. An unusual exertion, as heavy lifting or a 
strain, may develop a severe attack, probably of lumbago. 
Men suffer from it oftener than women, especially men whose 
occupation involves exposure. Previous attacks of the disease 
and the gouty and rheumatic habits are important predispos- 
ing causes. The affection occurs in the acute, subacute, and 
chronic form, and is frequently accompanied with articular 
rheumatism. 

No characteristic pathological features have been observed 
save, in case of death from muscular rheumatism, granular or 
vitreous degeneration of the muscular tissue. ' 

The symptoms are clear-cut, consisting chiefly of severe pain 
in the affected muscle. This may be a dull, bruised pain, or 
tearing, sharp, cramp-like. It may be constant or paroxysmal, 
or migratory, wandering from place to place. It is aggravated 
by changes in the atmosphere, toward evening, usually by the 
warmth of the bed, and intensely so by motion. To avoid the 
latter, the patient invariably seeks to maintain a position 
which allows relaxation of the affected parts. Severe pressure 
often affords relief. The disease really is local in character, and 



336 CONSTITUTIONAL DISEASES. 

rarely accompanied by constitutional symptoms, including 
fever. Its duration is variable; some attacks disappear in a 
few hours; others continue for several days; not infrequently 
they drag along for many weeks. 

As a matter of convenience special terms are used to denote 
involvement of different sets of muscles. Thus, lumbago affects 
the muscles of the loins and their attachments. It is a common 
form, frequently results from over-exertion, and is oftenest seen 
among laboring men who are obliged to lift heavy weights. It 
is exceedingly painful, rendering even slight motions, as turning 
in bed or rising into a sitting posture, practically impossible. 
Pleurodynia involves the intercostal muscles of one side — usually 
the left — , occasionally also the pectorals and the serratus 
magnus. The necessary maintenance of the respiratory move- 
ment renders physiological rest of the affected muscles impossi- 
ble, hence the distressing character of this form. The act of 
coughing or of a deep inspiration may become agonizing. It 
greatly resembles intercostal neuralgia, but the rheumatic pain 
is more continuous, less circumscribed, and there are no tender 
spots along the course of the nerves. From pleurisy it is differ- 
entiated by the absence of characteristic physical signs. Torti- 
collis or wry-neck involves the antero-lateral region of the neck, 
sometimes also the muscles of the back of the neck. It fixes the 
neck, so that the entire body must be turned in order to turn 
the neck. It usually affects one side, and is more often found 
among the young. In other cases the muscles of the abdomen 
may be affected; or those of the shoulders (scapulodynia); or of 
the upper back (omodjmia, dorsodynia); or those of the head 
(cephalodynia). 

The prognosis as to life is good. No serious complications, as 
of the heart, need be feared. The attacks, however, recur fre- 
quently. 

Treatment. — The necessity of wearing warm clothing and of 
avoiding exposure to dampness and cold is apparent. Persons 
who are subject to muscular rheumatism should make free use 
of alkaline mineral waters. 

An acute attack having begun, a Turkish bath, followed by 
massage and a thorough rubbing in alcohol, not infrequently 
stops it. Hot fomentations usually are grateful to the patient; 
in exceptional cases they may aggravate the pain. Electricity 



MUSCULAR RHEUMATISM. 337 

may be of service. Rockwell (Bigelow: International System 
of Electro-Therapeutics) recommends static electricity, though 
admitting that excellent results may be obtained from the 
galvanic or faradic current. He advises the use of the latter, 
preferably the galvanic, when the pain is of a neuralgic type, 
with much tenderness to pressure. When the pain is dull and 
aching, deep-seated, not aggravated, but possibly relieved, from 
pressure — as in the subacute or chronic form — he uses static 
electricity. "The method to be adopted is the simple one of 
insulation and submitting the patient to the effects of the roller 
electrode over the affected part." In pleurodynia, firm strap- 
ping of the side affords great relief. In lumbago, Osier speaks 
highly of Ringer's method of treatment by means of a puncture, 
thrusting needles, from three to five inches long, deep into the 
lumbar muscles at the seat of pain, withdrawing them after 
five to ten minutes; he states that relief often follows at once. 
Berberis. "In lumbago one of our most valuable remedies; 
pains extend from the back around the body and down the 
legs, with red and mucous sediment in the urine" (T. F. Allen). 
Recommended by J. T. O'Conner when there are renal, cystic, 
or hepatic complications. — Bryonia. Its specific indications 
are generally known. The remedy is often indicated and acts 
promptly. It does good work in all types of rheumatism, 
with stitching, tearing pain, made "worse from the slightest 
motion. Easy, profuse perspiration.— Cimicifuga. The fleshy 
part of the muscle is affected; twitching and jerking of the 
muscles, especially of the left side. Tendency to neuralgic affec- 
tions; stiffness and sense of contraction in the muscles of the 
neck and back; pleurodynia (right side); "electric shocks." — 
Dulcamara. After getting wet or cold; from living in damp 
rooms or from cooling the body when heated; from working in 
cold, damp places, cellars, ice-houses, etc. Stiffness or lame- 
ness across the neck and shoulder; lameness of the small of 
the back; severe drawing pains in the muscles of the back. 
When the weather has suddenly changed to damp cold. Stick- 
ing, drawing, tearing pains, often with a sensation of numb- 
ness. — Kalmia latifolia. The pains shift about constantly, 
are of a tearing, pressive, drawing character, and accompanied 
^vith a feeling of almost paralytic weakness. Severe pain at 
the heart. — Ledum. Pain changes location suddenly; it is of a 
22 



338 CONSTITUTIONAL DISEASES. 

sticking, tearing character, often "bruised"; affects also the 
smaller joints; coldness of the feet and of the affected parts; 
aggravation of the pain from the warmth of the bed. — Nux 
vomica. Wry-neck from cold and nervous shock. Rheumatism 
of the large muscles of the back, trunk, and neck; the back 
feels bruised and lame; aggravation from lying on the back, 
but he cannot turn over on account of the pain it causes; sensi- 
tiveness to cold air; chilliness from motion; paralytic weakness 
of legs; violent twitching and jerking of the affected muscles; 
irritability; characteristic gastro-intestinal symptoms. — Phy- 
tolacca. Subacute or chronic form, especially after the abuse 
of mercur\\ Shooting, lancinating, tearing pains; sometimes 
heavy aching; change locality often. Affects the tendinous at- 
tachments of muscles. Dorsal rheumatism. Worse from damp 
weather and at night. Obstinate rheumatism of the heels, 
only relieved by keeping the heels higher than the body. — Rhus 
toxicodendron. One of the best remedies when the muscles 
of the back are affected; with aggravations from cold and 
rising; better from bending backward and from dry heat. 
Lameness and stiffness in the back, with relief from continued 
motion. Drawing, tearing pain and intense lameness in the 
back. 

Consult also Causticum, Rhododendron, Pulsatilla, Ra- 
nunculus, Tarantula, Hamamelis. If chronic, CALCAREAand 
Lycopodium. 



GONORRHEAL RHEUMATISM. 

This affection is really a synovitis or arthritis, subacute in 
character and tedious in its duration, caused by infection from 
the urethral discharge during an attack of gonorrhoea. It 
occurs oftener in men than in women. It attacks the joints, by 
preference the knees and ankles, but also, exceptionally, joints 
which are usually exempt from rheumatism, as the sterno- 
clavicular, the inter-vertebral, temporo-maxillary and the sacro- 
iliac. 

"The inflammation is often peri-articular, and extends along 
the sheath of the tendons. When effusion occurs in the joints, 



GONORRHOEAE RHEUMATISM. 339 

it rarely becomes purulent. It has more commonly the char- 
acter of a synovitis. About the wrist and hand suppuration 
sometimes occurs in the sheaths. In the bacteriological exam- 
ination the gonococci have been found in the exudate, but not 
invariably. They may be present in the tissues, however, and 
cause an effusion which may be sterile." (Osier.) 

Clinical History. — Gonorrhoeal rheumatism commonly 
occurs from three to twelve weeks after the original gonor- 
rhoeal infection. It usually attacks the (left) knee, somewhat 
less often the ankle, the joint becoming stiff, slightly painful 
and swollen. The slowness with which the process develops in 
the joint establishes a large degree of tolerance; thus in the 
course of time the enlargement may become very great with- 
out causing severe pain, although rest at night in the more 
serious cases is usually much broken. Fluctuation in the joint, 
when the effusion is at its height, may be discovered by palpa- 
tion. No marked constitutional symptoms are observed. 
There may be copious sweating, but it is neither acid nor 
drenching like that of true rheumatism, from which it is further 
distinguished by the absence of sudden improvement of the 
affected articulation, of shifting from joint to joint, and of car- 
diac complications. 

Modifications of the course as outlined may occur. Occasion- 
ally the patient suffers much and long from wandering pains 
about the joints {arthralgic form); or several joints may be- 
come affected, with swelling, tenderness and light fever, closely 
resembling a subacute articular rheumatism, even giving rise 
to cerebral and cardiac complications {rheumatic form); or the 
affected joint may become the seat of extensive peri-articular 
oedema, with severe pain and, in exceptional cases, suppuration 
{acute gonorrhoeal arthritis); or the tendons, bursae, and peri- 
osteum rather than the articulation proper may be involved 
{bursal and synovial form); or there maybe chronic hydrar- 
throsis, involving one joint, preferably the knee, often without 
pain, redness, and swelling, and rarely with formation of pus. 

The course of this affection is exceedingly tedious, and fre- 
quent relapses occur. Once cured, the patient remains well, 
except as a new gonorrhoeal infection may bring on another 
attack of the disease, in -which case there is increased danger of 
permanent injury to the joint. Iritis is a not uncommon com- 
plication. 



340 CONSTITUTIONAL DISEASES. 

The diagnosis depends upon the history of gonorrhoeal infec- 
tion, upon the absence of acid sweating, the limitation of the 
disease usually to one joint, and the perverse, tedious character 
of the case. 

The prognosis as to life is good, but permanent injury to the 
articulation is liable to result from repeated attacks. 

Treatment. — Electricity (constant current) has done good 
service. Fixation of the joint and the thermo-cautery are indi- 
cated when the pain is severe; massage and passive motion 
may be used later. Incision and irrigation are now practised 
extensively among surgeons. If there are still present symp- 
toms of gonorrhoea, they should receive. prompt and careful 
attention. 

Excellent results have also been obtained by the long-con- 
tinued use of hot springs and mud-baths. 

Helmuth recommends Clematis when the disease sets in early 
after gonorrhoeal infection and when there is a tendency to 
orchitis. — Thuja when there is tearing, pulsating pain, or pain 
as from subcutaneous ulceration, with sensation of coldness or 
torpor of the part. — Veratrum, bruised feeling in the joints, 
better from walking; weakness and trembling in the affected 
parts. — Cimicifuga, Phytolacca, Kalmia, Gelsemium, Kali 

HYDRIODICUM, SEPIA, EUPHORBIUM, MERCURIUS SOLUBILIS, 

Stannum and Rhus are suggested by the same authority. 



RHEUMATIC ARTHRITIS. 

Synonyms: arthritis deformans; polypanarthritis; nodosity 
of the joints; progressive chronic articular rheumatism; gen- 
eral and partial chronic osteo-arthritis. 

A chronic disease of the joints of the extremities, with char- 
acteristic changes in the cartilages and synovial membranes, 
resulting in the formation of bony growths (osteophytes) and 
great deformity. 

^Etiology. — Rheumatic arthritis may occur at almost any 
time of life, but is usually seen after the meridian of ph^'sical 
vigor has passed, or, if earlier, under circumstances which show 
a premature decay of vital energy. It is much more frequent 



RHEUMATIC ARTHRITIS. 341 

in women than in men, and, according to Lyman, occurs espe- 
cially during the fifth decade of life. Statistics show that 
women from twenty to thirty years of age are frequently the 
victims of this affection, but its occurrence at that time of life 
is connected with child-birth, lactation, or too frequent child- 
bearing, a fact which seems to prove that physical exhaustion 
is in reality an exciting factor. Women suffering from uterine 
affections are said also to show a .tendency to the disease. In 
men rheumatic arthritis shows itself later in life, is more fre- 
quently the result of traumatism, and generally affects one of 
the large joints, as the hip. In the case of young children the dis- 
ease runs a rapid course and very pronounced deformities occur 
within a short time. Rheumatic arthritis is seen among both 
rich and poor, but the exposures and hardships which the 
laboring classes encounter daily render them particularly 
liable to the disease. The assertion is made that dampness 
and cold have not been proved to be etiological factors; it is, 
however,- true that persons exposed to these influences are 
among the chief victims of rheumatic arthritis. An inherited 
tendency (Garrod: 216 out of 500 cases) has been demonstrated 
in many instances, usually among families of scrofulous or 
phthisical habit, and most prevalent among the poor. Local 
injuries play an important part in the latter part of life, espe- 
cially in men, and they often result in such forms of rheumatic 
arthritis as morbus coxas senilis. 

The exact aetiology is still in doubt, but there is an inclina- 
tion to adopt the theory of the neurotic origin of rheumatic 
arthritis, as taught by Charcot, Benedikt, and Remak. In 
support of this theory the argument is advanced that the dis- 
ease commonly follows depressing influences, such as deep 
grief, worry and care; that it bears considerable resemblance 
to other joint deformities of established nerve origin; the sym- 
metrical distribution of the lesion; the extent of the muscular 
atrophy, which is often quite out of proportion to the extent 
of the local disease; and the occurrence of certain more distant 
effects which must be trophic, as in the skin and nails. 

Morbid Anatomy.— The changes going on in the affected joint 
begin with cell proliferation of the cartilage and synovial mem- 
brane; the cartilage assumes a soft velvety appearance, be- 
comes thin, eroded, is absorbed, and exposes the articular ex- 



342 CONSTITUTIONAL DISEASES. 

tremities of the bone. Protrusion of the thickened exterior 
margin of the articular cartilage results in the formation of ir- 
regular nodules which ossify (osteoplrytes) and b} T their pres- 
ence cripple and lock the joint. The denuded extremity of the 
bone assumes an ivory-like hardness and polish (eburnation). 
These changes eventualh^ result in a false anclndosis and de- 
formity of the articulation; when they occur in the vertebral 
articulations, they lead to true anclrylosis. In aged persons 
the affected bone becomes spongy, the spaces formed being 
filled with a soft substance not unlike marrow; atrophy of the 
heads of the diseased bones results as the effect of extensive 
wasting, and there are produced extraordinary deformities. 
Muscular atroplry in the neighborhood of the affected joint 
often is well marked, and neuritis of the peripheral nerves 
occurs frequently. 

Symptoms. — Charcot's division of rheumatic arthritis into 
a) Heberden's nodosities; b) general progressive form; c) mono- 
articular form, greatly facilitates an understanding of the clin- 
ical history. 

Heberden's nodosities (digitorum nodi) are hard nodules, 
formerly thought to be of gout}' origin, which appear on the 
sides of the last phalanges of the fingers. They are associated 
with tenderness, swelling, and slight redness; after a time, a 
bony growth on the ulnar side of the articulation pushes the 
terminal phalanx toward the radial side of the hand. The 
fingers are eventually drawn toward the ulnar side of the hand, 
with lateral distortion of the enlarged knuckle, mainly due to 
the relaxation of the articular ligaments. These nodosities 
appear oftener in women than in men, usually between the 
thirtieth and fortieth year of life, and are rarely accompanied 
with disturbances of the general health. There is no excessive 
pain, though considerable sensitiveness to rough touch or a 
knock, with periodic exacerbations at long intervals or from 
imprudence in diet. The condition is not curable, but involve- 
ment of the larger articulations is rare. 

The general progressive form, in its acute manifestation, is 
seen in young women of twenty to thirty years of age. It is 
liable to occur in connection with childbirth, over-lactation, too 
frequent pregnancies, or other severe drains from which women 
at that age suffer; it has also been observed at the menopause 



RHEUMATIC ARTHRITIS. 343 

and may occur in childhood. The first symptoms closely resem- 
ble articular rheumatism; many joints are simultaneously 
affected; there is considerable swelling, and frequently some 
fever. The. general health suffers more or less, but often after a 
time abatement of the symptoms brings relief until another 
pregnancy or confinement gives rise to a violent exacerbation. 
The chronic form, by far the more frequent, begins with stiff- 
ness in the joints which soon leads to a lack of accustomed 
dexterity, a serious affection when occurring in needle-workers 
and people who, like pianists, need nimbleness and deftness of 
the fingers. This stiffness at first is greatest in the morning, 
and passes off during the day, but soon becomes permanent. 
Then pain on movement is noticed, with slight swelling in the 
joint and its immediate neighborhood. The joints of the hand 
are first affected, then the knees and feet; gradually other artic- 
ulations are involved, symmetry of both sides of the body being 
maintained in the larger number of cases. Characteristic ana- 
tomical changes now occur, i. e., thickening of the capsular 
ligament, the formation of osteophytes, eburnation of the 
articular extremities of the bones, and, later, muscular retrac- 
tion. While these changes are taking place, a distinct crepita- 
tion sound maybe heard upon moving the joint. Soon spurious 
anchylosis results, muscular atrophy, contractures of muscles 
and flexion of the extremities, so that in an advanced case the 
patient is rendered absolutely helpless. Intense pain is fre- 
quently present. It may continue for many months, even 
years, but usually passes away when the more active changes 
in the joints have ceased. In some cases the patient enjoys 
freedom from acute suffering. 

The constitutional symptoms are wholly overshadowed by 
the local affection. There is usually indigestion, which is largely 
due to the enforced quiet of the patient, and there may be 
anaemia. 

The mental condition, during this period of ill health and suffer- 
ing, is naturally one of despondency and irritability. It is, how- 
ever, not unusual to see old people, far advanced in the disease 
and hopelessly crippled, enjoy good general health and be quite 
content, especially if there has been saved them a reasonable 
degree of usefulness of the hands. The latter is often the case 
since, as a rule, the thumb is not affected. The deformity of 



344 CONSTITUTIONAL DISEASES. 

the hand is such that it has frequently been compared to a 
"bird's claw" when first lifted from the perch. In the foot the 
disease commonly begins with involvement of the big toe. 

Rheumatic arthritis advances by exacerbations and abate- 
ments, and progresses symmetrically. 

The mono-articular form does not differ from the polyarticu- 
lar form save that it affects one joint only. It is a disease of 
advanced years, more particularly affects men, and frequently 
is the result of traumatism. If the hip is involved, it constitutes 
morbus coxa; senilis; if the vertebral articulations are its seat, 
spondylitis deformans results, producing fixation of the spinal 
column, etc., and if cervical, preventing any movement of the 
head save that of rotation. 

Diagnosis. — The diagnosis offers no difficulty. The occur- 
rence of the disease, often, in those who are old; its freedom 
from characteristic sour sweating, cardiac complications and, 
usually, fever; its progressive character and the permanency of 
its location in a certain joint, distinguish it from acute rheuma- 
tism. The involvement of so many joints and the characteristic 
deformities which follow should prevent its being taken for 
chronic rheumatism. From gout it is distinguished by the 
large number of articulations involved, by its slow and gradual 
development, the absence of chalky deposits about the joints 
elsewhere, and b} r the absence of those violent exacerbations to 
which sufferers from gout are subject. It is more difficult to 
differentiate between rheumatic arthritis and the local arthritis 
of the shoulder joint which is characterized by pain, thickening 
of the capsule and ligament, wasting of the shoulder-girdle 
muscles, and sometimes by neuritis. This affection of the 
shoulder-joint is curable in a majorit}' of the cases. 

Prognosis. — The prognosis, as to life, is good, many cases 
living to an old age. As to a cure, the outlook is practically 
hopeless, although arrest of the affection in an early stage may 
occur even without treatment, while in other cases a great 
deal of relief may be afforded b}^ taking appropriate measures. 

Treatment. — Residence of the patient throughout the year in 
a suitable climate and under proper sanitary and hygienic sur- 
roundings, with due attention to his minor ailments, such as 
indigestion, is important. Food should be both nourishing 
and easily digested. Stimulants, used in moderation, are kindly 



RHEUMATIC ARTHRITIS. 345 

borne and sometimes of service. Cod-liver oil is exceedingly 
useful. 

When there is much pain in the joint, perfect rest must be in- 
sured; the application of hot compresses at night will be found 
very comforting. After the pain has subsided, gentle friction 
should be used by the hour, to promote absorption of the effu- 
sion, improve the nutrition of the muscles and to maintain and 
restore mobility. Massage is of great importance and un- 
doubtedly tends to prevent the retraction of the muscles and 
subsequent flexion of a limb. Hot baths are advised in the 
early stage, but are considered worse than useless later. Cold 
baths and sea-bathing are prohibited. 

Electricity is both condemned and advocated. Lyman 
(Pepper's Amer. Textbook) advises galvanism "for the relief of 
pain and for the prevention of muscular atrophy and deformity. 
A large sponge electrode, representing the positive pole, should 
be placed upon the back of the neck or over the lumbar region, 
while the negative pole is connected with a dish of warm salt- 
water in which the feet are placed. The duration of the treat- 
ment should not exceed ten or fifteen minutes every day for the 
first month, after which time the applications may be made 
every other day or at longer intervals." 

As to medication, the dominant school cling to arsenic and to 
the iodides, usually the iodide of iron. Speaking from the 
standpoint of a homoeopath, it is safe to affirm that the old- 
time antipsorics hold the key to successful medication. Cal- 
CAREA carbonica, especially, covers a totality of symptoms 
which renders it exceedingly useful. — Lycopodkjm, Silica, 
Iodum, and Lithium carbon., constitute a group which ranks 
next in importance. Ammonium phosphoricum, Phosphorus, 
Kali hydriodicum, Nux vom., Benzoic acid, Causticum, 
Ledum, Rhododendron, Guaiacum, and other so-called "anti- 
rheumatic" remedies should be carefully studied. 

The totality of symptoms governs, and a close study of the 
materia medica affords the only means of arriving at the true 
remedy. 



346 CONSTITUTIONAL DISEASES. 



GOUT. 

Gout is a disorder of nutrition, characterized by the presence 
of uric acid in the blood, attacks of acute arthritis in one or 
more of the smaller joints, and the deposition of sodium urate 
in and about the joints; it is accompanied with irregular con- 
stitutional s\ r mptoms. 

./Etiology. — Heredity. In from forty to seventy-five per cent, 
of all cases parents or grandparents of the victims of gout have 
been sufferers from the same cause. It is almost always in- 
herited from a male ancestor, and, so far as age is concerned, 
most frequently attacks persons between thirty and forty 
3^ears old. In exceptional cases children, and even infants, have 
had gout. Persons well advanced in life have suddenly de- 
veloped the affection, but there is slight danger after the sixtieth 
year has been safely passed. It is generally conceded that the 
free use of alcoholic stimulants, especial^ of the heavier fer- 
mented liquors, is an important etiological factor, yet it can- 
not be denied that the facts frequently cited to disprove this 
assertion are of much weight. The same may be said concern- 
ing food. Constant liberal indulgence in meats is undoubtedly 
harmful, particularly in persons predisposed to gout, because 
such a diet lessens the alkalinity of the blood and its power to 
hold in solution the urates. Yet, many victims of gout have 
an excellent digestion in spite of their deliberately ignoring all 
restrictions as to diet, and others are great sufferers in spite 
of constant self-denial. 

An inherited tendency is by all means the most important 
predisposing cause, and high, generous living, free indulgence in 
all the pleasures of the table, and late and irregular hours are 
almost sure to intensify the predisposition, especially in persons 
who shun active physical exercise. These habits belong to the 
rich; hence the frequency of the affection among the upper 
classes. 

On the other hand, the poor are not exempt from gout. 
Laboring men who are much exposed to inclement weather, 
who do hard manual labor, and who indulge copiously in fer- 
mented liquors, especially in beer and porter, as do the ballast- 



gout. 347 

ers on the Thames, are often gouty. Workmen in lead, as com- 
positors, painters, and plumbers, also furnish a large per cent, 
of victims. 

The essential feature of gout is an increase of uric acid in the 
blood, due to increased production or lessened elimination, with 
a partial loss of the alkalinity of the blood. Garrod's theory is 
summed up as follows by J. T. O'Conner: "The normal amount 
of uric acid in the blood may be augmented either by increased 
production or by lessened elimination; in gout the kidneys are 
always implicated, functionally at first, and structurally in the 
chronic stages; the acid may exist in the circulating fluid, for a 
time at least, without the development of inflammatory symp- 
toms; true gouty inflammation is always accompanied by a 
deposition of urate of soda in the inflamed part; the deposit is 
crystalline and interstitial, and may be looked upon as the 
cause, and not the effect, of the gouty inflammation; the local 
inflammation in gout tends to the destruction of urate of soda 
in the blood of the inflamed part, and hence of the system gen- 
erally." 

While the uric acid theory is generally accepted, there is now 
a tendency to admit that Cullen may have been correct when 
he considered the nervous system the primary cause of all the 
mischief. "Uric acid is not the cause of gout; it is the gout, on 
the contrary, which causes the excess of the uric acid." (F. 
Woodbury, in Journ. of Amer. Med. Association.) The close 
relation held by depressing influences of mind and body to 
attacks of gout is one of the important facts cited in support of 
the nervous theory of the causation of gout. 

Morbid Anatomy. — The blood-serum contains uric acid, which, 
however, is also found in the serum of persons suffering from 
gravel, leucocythemia, and cirrhosis of the liver. The most 
striking pathological changes occur in the affected joints, which 
show a "chalky" appearance of the cartilage, due to infiltra- 
tion of urate of sodium; this infiltration extends to the liga- 
ments and neighboring tendons, and later affects the synovial 
membrane, urates appearing freely in the synovial fluid. Ero- 
sions of the articular cartilage occur in more advanced cases. 
The joints most frequently affected are the great toe, then the 
ankles, knees, and the small joints of the hands and wrists. 
Ulceration not infrequently takes place as the result of these 



348 CONSTITUTIONAL DISEASES. 

deposits, the ulcerated surface exposing solid concretions or 
discharging pasty masses of imperfectly crystallized urates, 
chiefly of sodium, but also urates of calcium in small amounts. 
The chalky deposits about the small joints result in stiffening, 
moderate deformity, and ankylosis. Chalk-stones (tophi) are 
also formed in other parts of the body, more commonly in the 
pinna of the ear along the margin of the helix; they have also 
been noticed in the eye-lids and alae of the nose, on the palmar 
surface of the fingers, on the ulna, tibia and corpora cavernosa 
of the penis; they lie immediately under the skin, and in size 
vary from a grain of sand to a pea. 

Ebstein looks upon the primary local changes as a local 
necrosis which is due to the presence of an excess of urates in 
the blood. The deposit, as has been stated, is always inter- 
stitial and is thickest at the part most distant from the circu- 
lation. 

The kidneys present the features of an interstitial nephritis 
(contracted kidney or arterio-sclerotic form) with deposits of 
uric acid in the straight uriniferous tubules, the pyramidal por- 
tions, calices and pelvis, and of urate of sodium in the connect- 
ive tissue parallel to the uriniferous tubules in the pyramidal 
portion of the kidneys. Circumscribed spots of necrotic tissue, 
cysts and, occasionally, anryloid degeneration have been ob- 
served. 

The heart is frequently hypertrophied on the left side; some- 
times there is dilatation of the heart cavities and fatty degen- 
eration of the heart muscle; deposits of urate of soda have been 
found on the valves. Atheromatous changes are not infrequent, 
resulting in partial obliteration of the lumen of the affected 
vessel and disturbances in the nutrition of the heart, brain, or 
other organs. The respiratory organs in rare cases show 
gouty deposits (vocal cords, walls of the bronchia), but em- 
physema, chronic bronchial catarrh and asthma are common 
in old cases. Liver. Fatty degeneration of the liver is common 
in obese sufferers from gout; cirrhosis is not infrequent, though, 
perhaps, due more often to habitual intemperance than to the 
presence of gout. Urates are rarely found in the alimentary 
canal. The gastro-intestinal disturbances which are so con- 
stantly seen in gouty patients are the effect of indigestion 
brought on by excessive eating and drinking; the brain symp- 



gout. 349 

toms occasionally observed are the result of vascular disturb- 
ances. 

Symptomatology. — Gout presents itself in the acute, chronic, 
and irregular form (lithaemia). 

Acute Gout. — An acute attack is usually, though not always, 
preceded by symptoms of indigestion, mental depression or 
irritability of temper, restlessness, especially at night, and 
twinges of pain in the small joints of hands and feet; the urine 
becomes acid, scanty, high-colored, and on cooling deposits 
urates. The paroxysm sets in during the early hours of the 
morning, usually between one and three o'clock, the patient 
being roused from sleep by an agonizing crushing pain, gen- 
erally in the ball of the (right) great toe, which rapidly grows 
in intensity. There is heat, swelling, shining redness and ex- 
treme tenderness of the part to touch, so that the weight of the 
blanket can scarcely be borne. With it, there is great restless- 
ness and a considerable fever, the temperature rising to 102° 
and 103°. Toward morning, at 5 or 6 a. m., the severity of 
the pain becomes greatly lessened, fever disappears, the bodily 
surface becomes moist, and the patient may fall into a sleep 
from which he awakens much refreshed, but with a swollen 
joint. The next night brings a repetition of the attack, run- 
ning the same course, and repeated nightly for from four to 
eight nights. 

In some cases other joints may be involved, especially the 
opposite great toe; exceptionally the pain may continue 
throughout the day. The inflammation never proceeds to sup- 
puration. Improvement is indicated by lessened tension of the 
skin over the affected joint and pitting on pressure; itching and 
desquamation of the skin accompany the subsidence of the 
swelling. 

The seizures in new cases usually occur during the spring 
months. The attacks leave the patient in improved general 
health, but with a very pronounced tendency to a recurrence of 
the paroxysm in four or six months, oftener a year. Recurring 
attacks invade successively the foot, ankles, knees, hands, 
wrists, and elbows; they grow less and less violent, but con- 
tinue for a longer period of time, and each time leave the 
patient in a less perfect state of health; in other words, the 
case becomes chronic. 



350 CONSTITUTIONAL DISEASES. 

Occasionally, during an acute attack the local symptoms 
suddenly show a remarkable improvement, even to complete 
disappearance; at the same time severe constitutional symp- 
toms set in which are always serious and may prove fatal. 
Such cases are described as cases of retrocedent or suppressed 
gout. The usual form of their expression is in the gastrointes- 
tinal tract (severe pain, vomiting, diarrhoea, profound pros- 
tration) or in the heart (pain, dyspnoea, irregularity of heart's 
action, sometimes acute pericarditis). Threatening cerebral 
symptoms may develop, as delirium, coma or apoplexy; these 
may be due to disease of the blood-vessels or to uraemia. 

Chronic Gout. — In the chronic form there is increasing fre- 
quency of the paroxysms, and less perfect recovery from each 
successive attack. In the course of time the permanent changes 
peculiar to gout are developed. The affection involves a larger 
number of joints; chalky deposits take place in the articulation 
and at distant points, with ulceration of the skin over the 
tophi and, often, free exposure of the concretions at the 
knuckles. Dyspepsia may prove persistent; arterio-sclerosis 
and later cardiac hypertrophy (left-sided) develop; the urine is 
of persistently low specific gravity, and the patient suffers from 
the many and varied symptoms which arise from involvement 
of the kidneys, heart, and other organs, which have been de- 
scribed. 

Irregular Gout. — Under this head are comprised a train of 
well-defined symptoms which in their totality constitute the 
lithaemic or arthritic diathesis. Lithaemia is inherited or ac- 
quired, oftener the former. It makes itself felt throughout life, 
and is characterized by an excess of uric acid in the S3 r stem, re- 
sulting in periods of irritation of the nervous system which is 
expressed chiefly by hemicrania, neuralgia, vertigo, tinnitus 
aurium, flushing of the face, sensory disturbances, mental de- 
pression and irritability, and eruptions of the skin, commonly 
of an eczematous character. The direct cause of these 
symptoms is undoubtedly a disordered nutrition, inherited or 
acquired. Lithasmia, though entailing a great deal of annoy- 
ance, may exist throughout life without a well-defined out- 
break of gout. 

The lithaemic diathesis in early childhood finds its most 
common expression in eruptions of the skin, chiefly eczema and 



GOUT. 351 

impetigo, with pronounced tendency to catarrh of the respira- 
tory mucous membrane; in such cases cold in the head, sore 
throat, tonsillitis and bronchitis result from trivial exposure, 
and not infrequently alternate with cutaneous eruptions. 
Susceptibility to arthritic rheumatism becomes evident as the 
child approaches puberty. In early adult life the same ten- 
dency to catarrh is seen, often throwing itself upon the genito- 
urinary mucous membrane; there are frequent and easily pro- 
voked blennorrhagic and gonorrhceal affections which readily 
extend into the bladder and epididymis. Urethritis often occurs 
from a pure intercourse, and even spontaneously. The eczema- 
tous tendency continues, and corpulent lithaemics suffer much 
from erythema and intertrigo. During the years of mature 
adult life indigestion develops, of an acid character, with head- 
ache, constipation or gastro-intestinal catarrh, and itching, at 
times bleeding, haemorrhoids. The respiratory mucous mem- 
brane still maintains its hypersensitiveness and irritability, as 
is shown by naso-pharyngeal catarrh, often extending into the 
middle ear, and chronic bronchitis. In due time, the nervous 
system gives evidence of great weakness and irritability, and 
the patient suffers from headaches, dizziness, peevishness, fret- 
fulness, disinclination to mental effort, torpidity of the liver and 
a settled disposition to so-called biliousness. The urine, all 
this time, is acid and high-colored, containing lithic acid, crys- 
tals of which may be deposited on standing. 

Gouty glycosuria and oxaluria may be present at certain 
periods, and there is said to be a special liability to the forma- 
tion of calculi, an assertion which, however, is denied by some 
authorities. Arterio-sclerosis may occur as a renal, cardiac, or 
purely vascular manifestation. Aneurism is a possible conse- 
quence of such changes, and fatal results may follow the rupture 
of a blood-vessel; if in the brain, apoplexy occurs. 

Diagnosis. — Gout is distinguished from articular rheumatism 
by the history of a gouty predisposition, mode of living, ap- 
pearance of the attack, and for a long time fixation in one 
joint; unusual tenacity, as to duration; close relation between 
the height of the fever and the intensity of the local inflamma- 
tion; frequency of gastric disturbances; characteristic renal and 
cardiac complications; relative importance of diet in its effect 
upon the case. Chronic rheumatism has a preference for large 



352 CONSTITUTIONAL DISEASES. 

joints; gout for small joints. The differentiation between gout 
and arthritis deformans is drawn by Whittaker as follows: 
"Gout affects most frequently males, arthritis females. Gout 
chiefly affects the upper, arthritis the lower, classes. Gout 
begins in the toes, arthritis in the fingers. Gout swells and 
dislocates the joints of the big toe, and afterward of the other 
toes. Arthritis commences by preference in the fingers, which 
it also swells and dislocates, as a rule, in a more regular way, 
so as to imbricate the joints of the first three fingers, pointing 
the fingers toward the ulna. Gout, when it affects the hand, 
does not to the degree of arthritis spare the thumb. The de- 
formities of arthritis are produced by outgrowths of bone; of 
gout, b}' deposits of sodium urate. So-called cases of rheu- 
matic gout are supposed to represent mixed forms or coincident 
attacks. The possibility of such a condition may not be denied, 
but an autopsy decides always in favor of one or the other. 
In a doubtful case the blood may be examined for urate of 
sodium. If two drachms of blood serum be slightly acidulated 
with acetic acid in a watch-glass, and a linen thread be sus- 
pended or laid across the glass, the thread will be found after 
twenty-four hours covered with crystals of uric acid. Uric acid 
may also be crystallized out of the fluid of a blister not too near 
the joint. It is needless to say that this excess of uric acid can- 
not be detected in rheumatism in any form or in arthritis 
deformans. It belongs exclusively to*gout." 

Prognosis. — The prognosis of acute gout, as to duration of 
life, is good; in the chronic form, especially in the absence of 
proper habits of living, it is seriously affected by the complica- 
tions which are liable to occur. 

Treatment. — The chief aim of treatment must be the eradica- 
tion, if possible, of the predisposition to gout, or the arthritic 
diathesis. Success depends upon the exercise of patience, 
thoroughness in the study of each individual case, good judg- 
ment in outlining the things to be done and those to be avoided, 
and tact in securing the hearty cooperation of the patient. 

The need of such attention to clothing as will reduce to a 
minimum danger of taking cold from exposure to sudden 
changes of temperature or chilling of the body, as well as resi- 
dence in a climate which will as far as possible lessen this 
danger, is so apparent that bare mention is sufficient. Active 



gout. 353 

exercise, always stopping short of fatigue, is equally important. 
To young persons every form of moderate exercise, espe- 
cially in the open air, is to be commended, since an active life is 
one of the most efficient means of maintaining a good digestion, 
proper assimilation of food, and prompt elimination of waste 
products. Persons who are advanced in life must be as active 
as their strength allows and, if too feeble to take active exer- 
cise, must have the full benefit of massage or Swedish move- 
ment. The importance of this advice can hardly be overesti- 
mated. 

Diet. — The impossibility of laying-down fixed dietetic rules 
which shall apply to all cases is now very generally realized; in 
fact, a large portion of the benefit to be derived from careful at- 
tention to diet depends upon the amount of discrimination 
used. Both quantity and quality of food require attention, 
and of the two, the former is the more important. All the 
rules concerning the diet of gouty persons are compressed in 
eating with moderation and in reducing very materially the 
amount of nitrogenous food and of carbo-hydrates usually 
taken. As to meats, they should always be used sparingly. In 
children and young persons it is well to dispense with them 
almost entirely; but it is not wise to withdraw them alto- 
gether in the case of older persons who are accustomed to 
them. Meat once a day can safely be taken by the majority of 
gouty people who live a moderately active life; if of persistently 
sedentary habit, it is wise to limit the amount which may be 
eaten even at this one meal. White meat is preferable to dark. It 
is always best roasted. Pork, especially salt-pork, and veal are 
bad; oysters, egg and fish are good; lobster, crabs, etc., must be 
prohibited, particularly in the form of salads. Fat meat must 
be avoided by corpulent gouty persons. 

Fruit may be used according to natural desire if it does not 
derange digestion; it should be thoroughly ripe, and eaten 
without sugar. Oranges and lemons are least liable to do mis- 
chief; melons, bananas, peaches, and other sweet fruits, must 
be taken cautiously, if at all. 

Of vegetables, potato must be used sparingly; spinach, let- 
tuce, tomatoes and cucumbers are allowable; asparagus, 
rhubarb and sorrel should be avoided. Hot cakes, hot rolls, 
corn, and the various preparations derived from it, are for- 
23 



354 CONSTITUTIONAL DISEASES. 

bidden articles of diet. Milk is excellent and may be used in 
large amounts unless, owing to some idiosyncrasy, it disagrees 
with the patient. Starchy and saccharine articles of food are 
largely under the ban. Concerning the use of sugar, Duckworth 
points out that by itself it is not necessarily harmful to the 
gouty; "but there is evidence to show that if it be freely taken 
in addition to a varied and mixed diet, especially with certain 
articles and with wine, an imperfect fermentative process is set 
up in the stomach and small intestines which tends to provoke 
flatulency and acidit}\ It is therefore in this manner that 
sugar proves harmful to those disposed to gout." 

As to drink, water, milk, mineral waters, and milk and 
potash-water may be taken ad libitum. Alcohol must be used 
very cautiously, if at all. Children who have inherited the 
gouty tendency must under no circumstances be allowed to use 
alcoholic stimulants, nor the use of ale, porter, beer, or cider; 
neither should they be permitted to drink tea or coffee. Adults 
must generally follow the same course of abstinence. Heavy 
malt liquors and sweet wines, especially champagne, are abso- 
lutely forbidden; dry sherry, claret, white wine, old Bordeaux 
and whiskey without sugar may be used if total abstinence 
cannot be enforced. 

Of mineral waters, the Carlsbad, Fachingen, Wiessbaden, 
Kissingen and Vichy, on the European continent, and the 
Harrogate and Bath, in England, have an extensive reputa- 
tion; to have the full benefit of their action, the patient should, 
however, reside at the springs for a considerable length of time. 
Of American waters which have proved of value in the treat- 
ment of the gouty diathesis the best known are the Saratoga 
(N. Y.), St. Claire Springs (Mich.), White Sulphur (Va.), Cale- 
donia and St. Catherine Springs (Canada). 

Among other measures to be employed are: regular bathing, 
in the morning or evening, followed by friction, and an occa- 
sional Turkish bath, with massage. 

In an acute attack of gout the limb should be elevated, the 
joint being wrapped in some soft substance (flannel or, better, 
cotton wool), with the limb supported on a pillow and covered 
with a light frame upon which to rest the bed-clothes. 

The pain may be relieved by the use of hot fomentations, 
Fuller's solution, hot whiske\r and water applied on soft cloths 



gout. 355 

(absorbent cotton) on the surface of which tincture of opium 
or of belladonna may be sprinkled. Extract of hamamelis, 
similarly used, is often very grateful to the patient. 

The general management consists of care in diet, gentleness 
and patience in handling the affected limb, enforced quiet and 
rest of mind and body of the patient, the use of Seltzer water, 
Apollinaris or potash water for drinking purposes, and the 
exhibition of the indicated remedy. The use of morphia, by 
the mouth or hypodermically, is discountenanced by some of 
the best authorities of the dominant school. Vomiting may be 
relieved by sucking bits of ice; a few drops of chloroform in 
ice water often stops annoying hiccough; mustard plaster and 
hot poultices are occasionally required when there is much 
pain in the stomach. 

Should retrocession take place, every means must be em- 
ployed to reestablish the inflammation in the primarily affected 
joint; counter-irritation by means of mustard foot-baths is 
most liable to accomplish this. 

Chronic gout requires little, if any, local treatment. If there 
is ulceration and pus-formation, surgical measures may become 
necessary. Osier recommends the use of citrate of lithium, five 
grains three times per day, in a glassful of potash- water. 

Therapeutics. — The therapeutics of gout are in a state of 
lamentable paucity. As yet, no system of therapeutics has 
produced a remedy which can be prescribed with the assurance 
that it will give positive curative effects, save Colchicum, 
which in acute attacks greatly and promptly relieves the pain 
and appears to cut short the attack. The symptoms which the 
drug has produced upon its provers afford reasonable grounds 
for the claim that its action here is purely homoeopathic. 

Colchicum "has in a majority of cases a powerful influence 
over the symptoms, relieving the pain and reducing, sometimes, 
with great rapidity the swelling and redness. It should be 
promptly stopped as soon as it has relieved the pain." (Osier.) 
If not promptly stopped, violent purging and great general de- 
pression are sure to result when the drug is administered in the 
doses of the dominant school, i.e., from twenty to thirty minims 
of the wine of colchicum every four hours. Much smaller doses, 
given at shorter intervals, yield better results. 

The symptoms indicating the use of Colchicum homoeo- 



356 CONSTITUTIONAL DISEASES. 

pathically are: dark-red swelling and heat of the great toe- 
joint, with excessive sensitiveness to touch, violent tearing or 
sharp sticking pains, with extreme soreness in the toe, heel, and 
small joints. Sensitiveness to strong odors of any kind; he 
craves a certain article of food, but when it is brought him, the 
sight and the smell of it nauseate him, and he refuses to takeit. 
Mental irritability and peevishness. Great prostration. Urine 
dark and scanty (but the excretion of urea or uric acid is not 
modified). The powerful action of CoLCHicuMupon the gastro- 
intestinal canal, with violent retching and vomiting of food 
and bile, coldness of the stomach and jelly-like dysenteric stools, 
accompanied with great tenesmus and prostration, recommend 
its use when such symptoms occur from sudden retrocession or 
suppression of gout. The heart symptoms of the drug are 
also well-defined (anxiety, pressure, tearing pain and stitch- 
ing in the precordial region; great oppression and difficuhy of 
breathing; weak and indistinct action of the heart; thready 
pulse, etc.), often call for its exhibition when cardiaccompli- 
cations arise. — Arnica: painful, hard, shining swelling of the 
affected part. Great sensitiveness of the bod}-. "The bed feels 
too hard." Excessive prostration. " Fear of persons coming 
toward him, as if they would strike him." (T. F. Allen.) — 
Benzoic acid is credited with causing symptoms of a uric 
acid diathesis, with swelling of the joints and pains in the 
joints and tendons of a sticking, burning, tearing, stitching 
character. The urine is dark-brown, acid, very offensive, and 
of high specific gravity. — Ledum is indicated in rheumatic 
rather than gouty^ affections, but its provings yield many 
s\-mptoms in the small joints which closely resemble gout. The 
pains are drawing, tearing, grinding and, if rheumatic, shift- 
ing. They are made much worse from the warmth of the bed. 
— Lithium carbon. "Is generally indicated in a gouty diathe- 
sis, with recurring attacks of acute inflammation of the small 
joints or of the heart. The skin of the Lithium patient is very- 
rough and dry." — Lycopodium is undoubtedly one of our best 
remedies in the treatment of the lithremic state. Its use rests 
upon the presence of familiar indications, as the acid, atonic 
dyspepsia and hepatic symptoms which so closely resemble the 
digestive disturbances peculiar to lithremia; it also covers 
respiratory symptoms which are frequently present. Chronic 



DIABETES MELEITUS. 357 

gout, with chalky deposits in the joints; eczematous and her- 
petic eruptions. — Sabina. "The great toe is hot, swollen, red, 
and extremely painful, with aggravations at the least touch or 
motion, and with some relief from cold applications. High 
fever, worse in the evening. Heaviness in the affected limb. 
Frequent change in position to obtain some alleviation." The 
open air feels grateful; general depression; pulsations in differ- 
ent blood-vessels. — Nux vomica is often called for by symptoms 
of gastro-intestinal derangement; it may prove of benefit in an 
acute attack of gout occurring as the direct result of gormand- 
izing and too free indulgence in stimulants. Irritability of 
temper is especially marked. — Guaiacum has been used of late 
for gout, though much closer related to chronic rheumatic 
arthritis. H. C. Houghton reports a case of "gouty otitis" 
cured under its exhibition, but the value of the report is im- 
paired by the use of intercurrents. It is said to act best when 
the left side is affected. — The exhibition of Aconite and Bryonia 
during the early stage, of Veratrum viride (great arterial ten- 
sion, high temperature), China, Terebinthina (nephritic com- 
plications; dark, cloudy urine with dirty pink sediment) and 
Plumbum (contracted kidney) is justified by the presence of 
their well-known characteristics. 



DIABETES MELLITUS. 

Diabetes mellitus or saccharine diabetes is a disorder of nu- 
trition characterized by the persistent accumulation of sugar in 
the blood, which is excreted from the system through the urine. 
The constitutional symptoms are: inordinate thirst, ravenous 
hunger, copious emissions of saccharine urine and progressive 
wasting of the body, with great exhaustion. The disease 
almost invariably terminates fatally. 

Etiology.— Heredity is an important factor. Purdy states 
that in 30 per cent, of all cases the predisposition to diabetes is 
inherited, and both Ralfe and Sir H. Marsh have furnished in- 
stances of its appearing through four successive generations; in 
a very large number of cases the neurotic temperament was 
well pronounced. Nearly two-thirds of the cases occurred in 



358 CONSTITUTIONAL DISEASES. 

males, especially in persons from the third to the sixth decade 
of life. Cases of young infants suffering from diabetes have 
been reported, but they are as exceptional as those which first 
declare themselves during old age. The disease has a prefer- 
ence for a cold climate and high altitude, and is oftener seen in 
the city than in the country. Hebrews are strangely subject to 
it, Frerichs stating that one-fourth of all his cases belonged to 
that race. The higher classes of society furnish a large per 
cent, of the victims. Sudden obesity has been observed to pre- 
cede diabetes. The affection is oftener seen in Europe than in 
America, statistics showing that whereas, according to the last 
census, in America there were 2.8 cases to each 100,000 popula- 
tion, from 5 to 9 were reported in Europe. 

Of exciting causes, serious impairment of the nervous system 
by shock, overwork, the strain of great responsibility, anxiety 
and worry are among the most important, particularly when 
associated with close confinement and high living. A disor- 
dered nutrition, from careless eating or from overeating, be- 
yond doubt often excites a latent tendency to diabetes, and to 
this cause is assigned its frequency among the Jews. Cases 
have been traced to injuries of the brain and spinal cord, espe- 
cially, but not necessarily, those involving the medulla oblon- 
gata (as blows and falls upon the forehead, vertex or occiput), 
and to irritative lesions of Bernard's diabetic centre. Gout, 
malaria and syphilis are by some authors associated with dia- 
betes. Exhausting and particularly infectious diseases, by 
their depressing effects upon the nervous system, are at times 
followed by diabetes; for the same reason pregnancy and dia- 
betes are often associated. Glycosuria, usually the result of 
overeating, especially of too free indulgence in starchy food, 
may call into action a latent predisposition to diabetes. 

The real nature of diabetes is not understood. Purdy (1890), 
after a very thorough consideration of the theories and facts 
advanced, comes to these conclusions: "(a) That the essential 
feature of diabetes consists of a more or less profound disturb- 
ance of the grycogenic function of the liver, (b) That the chem- 
ico-physiological changes in diabetes result in arrest of the 
elaboration of certain foods in their course toward their ulti- 
mate destination in the organism,— probably as fats, — and the 
intermediate product, passing into the general circulation, es- 



DIABETES MELLITUS. 359 

capes from the system, chiefly by way of the kidneys, in the 
form of sugar, (c) That the disease is accompanied by a hyper- 
acute condition of the liver and a more or less engorged state 
of the chylopoietic viscera, (d) That recently ascertained facts 
indicate that, in addition to the liver, the pancreas also is con- 
cerned in the production of sugar in the organism, — or, to speak 
more accurately, in preventing the production of sugar in the 
organism,— and consequently diseases of the latter organ are 
liable to induce diabetes, (e) That diabetes may be brought 
about by diseases which involve the central ganglia that pre- 
side over the vaso-motor nerves of the liver, l5y diseases affect- 
ing the peripheral distribution of these nerves, and probably 
also by disorders involving inhibitory reflex action of the sym- 
pathetic nervous system." 

During the last few years extensive inquiry has been made 
into the part played by affections of the pancreas in the produc- 
tion of diabetes, started by the frequency with which lesions of 
that organ have been observed in persons dead from diabetes. 
Experiments show that extirpation of the pancreas in dogs 
causes glycosuria (a patient of W.T. Bull died of diabetes after 
extirpation of the pancreas); but if the extirpation is incom- 
plete, a small portion of the gland remaining, such result is not 
produced. "The pancreas, on this view, like the liver, has a 
double secretion — an external, which is poured into the intes- 
tines, and an internal, which is poured into the blood. The 
latter is supposed to be of the nature of a ferment, in the pres- 
ence of which alone the normal assimilative processes can take 
place with the glycogen. Disease of the pancreas causes dia- 
betes by preventing the formation of the glycolytic ferment." 
(Osier.) 

Morbid Anatomy. — The nervous system presents no lesions 
which may be considered characteristic. The liver often, but 
not always, is enlarged, sometimes slightly, again to two or 
three times its normal size; if enlarged, it is of dark color and 
of hard texture. "The essential and most constant changes 
found are marked dilatation of the hepatic capillaries, hyaline 
thickening of the walls of the latter, and slight interstitial 
overgrowth surrounding the hepatic cells, either individually or 
in clusters and extending along the walls of the interlobular 
plexuses. In addition to this, the vessels are distended and en- 



360 CONSTITUTIONAL DISEASES. 

larged; the liver-cells swollen, somewhat granular, and indis- 
tinct in their outlines, with diminished amount or absence of 
the normal fat contents." (Purdy.) The heart (left ventricle) 
is enlarged in about fifteen per cent, of the cases; fatty degener- 
ation of the heart and of the arterial walls is common; dilata- 
tion is frequent; increased vascular tension is often observed 
during life. The blood contains a large amount of sugar (from 
}4 to Vo per cent., or more) and sufficient fat to give to it a more 
or less milky appearance. There is loss of solids, lessening of 
alkalinitjr, and increase in the proportion of water. The lungs 
frequently are involved in tuberculous processes or suffer from 
circumscribed areas of pneumonic inflammation, with hepatiza- 
tion and tendency to breaking-down of tissue and the forma- 
tion of cavities. The pancreas, it is estimated, shows distinct 
changes in about one-half of the cases. Atroph}- of the gland 
is the most common, the result of connective tissue changes or 
of obstruction of the ducts from calculi; cysts are occasionally 
formed from the latter cause. The kidneys suffer because of the 
large amount of work thrown upon them and from irritation 
caused by the presence of sugar. The organ is enlarged, over- 
filled with blood, and presents a smooth surface with non- 
adherent capsule. Hyaline changes take place in the tubular 
epithelium. The cells of the large medullary tubes become 
swollen, clear, and are recognized with difficulty (dropsical de- 
generation of Cantani). 

Symptoms.— While exceptionally, as after the receipt of an 
injury or after some sudden and profound emotion, symptoms 
of diabetes may set in without warning and develop rapidly, 
in the great majority of cases the onset is stealthy, and the sus- 
picions of the patient are not roused until large amounts of 
urine are secreted, with insatiable thirst, ravenous hunger, and 
progressive and usually rapid emaciation, — symptoms which 
practically constitute diabetes. The urine is pale, watery, of 
sweet odor, sweet taste, acid in reaction, and of high specific 
gravity, averaging from 1.025 to 1.045. The amount voided 
within the twenty -four hours varies from three or four quarts 
to several gallons in severe cases. It contains sugar ranging 
from one and a-half to two per cent, in mild cases to five, eight 
or even ten per cent, in severe cases, and has reached the enor- 
mous amount of one or two pounds in twenty-four hours. The 



DIABETES IvIELEITUS. 361 

amount of urine passed is reduced under proper diet and by in- 
tercurrent acute (febrile) diseases. Thirst is constant and so 
violent that it cannot be quenched; in unusually bad cases it is 
agonizing. The large amount of water is needed to keep in so- 
lution the sugar and to facilitate its excretion. Thirst is worse 
after eating. In exceptional cases it is moderate throughout, 
with corresponding moderate excretion of urine. There is 
dryness of the mouth and lips, which is not relieved by drink- 
ing; dry, glazed tongue, and scantiness of the salivary flow. 
The appetite usually is voracious, especially in the early part of 
the case. Eventually, as the result of overtaxed digestion, loss 
of appetite may occur, with other symptoms of indigestion, 
such as constipation or diarrhoea, often accompanied with 
swelling and soreness of the gums and, later, aphthous stoma- 
titis. Emaciation is marked and in proportion to the amount 
of sugar excreted. The skin becomes dry and harsh; the breath 
has the odor of rotten apples; the temperature is lowered, 
averaging from 96° to 97°, sometimes falling much lower; 
there is shivering and great sensitiveness to cold, with taking 
cold from slight exposure; the pulse is frequent, with increased 
tension in the majority of cases. 

The case progressing, manifestations of exhaustion and irri- 
tability of the nervous system appear (somnolence, neuralgia, 
cramps, sensory derangements, as cutaneous hyperesthesia, 
sensation of great heat, sudden sweating, etc.), with irrita- 
bility, fretfulness, loss of sexual power, impairment of mental 
vigor, great bodily weakness and general apathy. Pulmonary 
and other complications, especially cardiac disturbances, now- 
set in, with difficulty of breathing, praecordial distress, and 
death from general exhaustion, from some complication, as 
phthisis or gangrene, or from diabetic coma. 

Various complications arise in the course of the disease and 
materially modify the clinical picture presented. Of these, the 
pulmonary complications are among the most important; they 
consist of pneumonia of an acute character, lobar or lobular, 
tuberculous affections, and gangrene (less fetid than in the or- 
dinary form). Renal complications are comparatively frequent, 
particularly albuminuria. Usually it is trifling, but in excep- 
tional cases and late in the course of the disease it arises from 
structural implication of the kidney, and then is serious. It is 



362 CONSTITUTIONAL DISEASES. 

often met in connection with diabetic phthisis, occasionally 
with arterio-sclerosis, and sometimes it precedes diabetic coma. 
Cutaneous affections are a source of great annoyance and even 
danger. Eczema, accompanied with terrible itching, is common. 
Intense irritation of the genito-urinary mucous membrane 
(pruritus pudendi, balanitis) causes much distress. Boils and 
carbuncles are frequent and often constitute a serious feature 
of a case, giving rise to much pain and exhaustion. Gangrene, 
also, is not uncommon. The nervous disturbances are varied. 
Mam- of them are due to the irritability of weakness, as the 
numbness, tingling, muscular weakness and neuralgia in dif- 
ferent parts of the body. Peripheral neuritis often occurs, 
giving rise to neuralgia (symmetrical), especially of the sciatic 
nerve; trophic disturbances are liable to result from the same 
cause, such as loss of hair and nails, and even perforating 
ulcers. The paraplegia, occasionally quite extensive and even 
affecting both arms and legs, and the minor transitory par- 
alyses seen, are probably due to neuritis. The so-called diabetic 
tabes (pseudo-tabes), differentiated from true tabes by the 
rapidity of its development and its prompt subsidence when 
there is improvement in the diabetic condition, is accompanied 
by impairment or loss of the patellar and other tendon-reflexes, 
lightning-pains in the legs, and characteristic gait. When dia- 
betes is the result of irritation or disease of the fourth ventricle, 
the patellar reflex is liable to be exaggerated. The mental con- 
dition is one, usually, of great depression; commonly there is 
loss of sexual power. Of the special senses the organs of vision 
and of hearing are affected in the greater number of cases. It 
is stated that nearly all the paralytic and inflammatory dis- 
eases of the eye may occur in connection with diabetes, as cata- 
ract, retinitis, haemorrhages, sudden amaurosis, paralysis of 
the muscles of accommodation and atrophy of the optic nerve. 
Of aural affections, otitis media is the most common; inflam- 
mation of the mastoid cells is occasionally seen. Impairment 
of the sense of taste or of smell is rare. Diabetic coma is the 
most important and serious complication, about one-half, if 
not more, of all cases of diabetes terminating in coma. It has 
been extensively studied by Kuessmaul, Frerichs, and others, 
but its nature is not yet understood. The weight of testimony 
tends to show that it is due to some poisonous substance in the 



DIABETES MELLITUS. 363 

blood, probably acetone. Frerichs distinguishes three forms: 
cases in which weakness, syncope, somnolence and coma de- 
velop within the course of a few hours, after a violent exer- 
tion; cases in which there is some local affection (as pharyn- 
gitis, carbuncles) or a pulmonary complication, or preliminary 
gastric derangement, with headache, delirium, dyspnoea, in- 
tense difficulty of breathing (Kuessmaul: "Luft-hunger"), 
rapid and weak pulse, gradually developing fatal coma in from 
one to five days; and cases where the patient without warning 
is suddenly seized with headache and feeling of intoxication, 
rapidly drifting into profound coma. . It is stated that there is 
great danger of coma whenever the quantity of urine is sud- 
denly diminished without a corresponding reduction in the rel- 
ative amount of sugar. 

Duration and Prognosis. — The age of the patient at the time 
diabetes first appears is of great importance, since observation 
shows that the older the patient at the time the first symptoms 
appear, the more tedious the progress of the disease. In 
young children the disease runs a rapidly fatal course, from a 
few weeks to a few months. In young people, shortly before 
the age of puberty, the duration is rarely more than two years. 
In elderly persons, with tendency to obesity and arthritic rheu- 
matism, the duration is from fifteen to thirty years, unless ac- 
companied with pancreatic disease; if the pancreas is involved, 
death is liable to occur within two years. Pregnancy in a dia- 
betic patient is a serious complication. Abortion takes place 
in one-third of such cases, and delivery in one-half of them is 
followed by coma or grave pulmonary symptoms. Diabetes 
suddenly appearing in a person of rugged health is liable to run 
a rapid course to a fatal termination. If the result of an injury, 
the prognosis is favorable if the disease appears at once, such 
cases often recovering in a few months; if the first symptoms 
do not appear until a considerable period of time has elapsed, 
the prognosis is grave. Heredity always adds to the gravity 
of the situation. In fact, it is generally admitted that the dis- 
ease is practically incurable. 

Diagnosis. — The diagnosis rests upon the constant presence 
of sugar in the urine, and is so clear that a mistake cannot 
readily be made. The following tests are easily made and re- 
liable: 



364 CONSTITUTIONAL DISEASES. 

Trommer's Test. — Treat one drachm of the urine with suffi- 
cient cupric-sulphate solution to render it of light-green color, 
then add an equal volume of liquor potassas. At first a blue 
precipitate of hydrated cupric protoxide results, which dis- 
solves upon shaking, forming a clear, blue solution. If allowed 
to stand about half an hour, there will be a precipitation of 
yellow or yellowish-red suboxide of copper. The application of 
gentle heat, instead of standing, renders the test more delicate, 
and precipitation occurs at once; but the solution must not be 
boiled long, lest the test be rendered oversensitive. 

Fehling's Test is easily made and reliable, provided the solu- 
tion is made fresh. The original formula is: 34,639 grammes 
of pure crystallized cupric sulphate; solution of sodium hy- 
droxid (spec, gravity, 1.12), about 500 cubic centimetres; 
chemically pure neutral sodium tartrate, 173 grammes. Dis- 
solve the copper sulphate in 100 cubic centimetres of distilled 
water; next dissolve the neutral sodium tartrate in the caustic- 
sodium solution, and add the copper solution little by little; 
then, with distilled water bring the volume of the whole to 
1000 cubic centimetres. Apply as follows: dilute one drachm 
with an equal bulk of distilled water in a test tube, and gently 
boil for a few seconds. If it remain clear, add the suspected 
urine, drop by drop, and if sugar be present, the first few drops 
will usually cause a yellow precipitate. If no precipitate occur, 
continue dropping until one drachm, not more, of urine be 
added, reapplying the heat occasionally. If no precipitate 
occur, sugar is, clinically speaking, absent. 

Hame's Test.— Take pure copper sulphate, 30 grs.; distilled 
water, V2 oz.; make a perfect solution and add of pure glycer- 
ine, V2 oz.; mix thoroughly and add 5 oz. of liquor potassas. 
Apply as follows: gently boil one drachm of this solution in an 
ordinary test-tube. Add, not to exceed, 6 to 8 drops of the sus- 
pected urine, and again boil gently. A copious yellow or yel- 
lowish-red precipitate will be thrown down if sugar be present. 
This test is easily made, and the fluid remains reliable for an 
indefinite time. 

The Fermentation Test will detect sugar if present in consid- 
erable quantity, not less than one per cent., but it requires sev- 
eral hours. "Fill an ordinary test-tube half full of mercury and 
the remaining half of the urine to be tested, and introduce into 



DIABETES MELLITUS. 365 

the urine a small piece of German yeast. Next close the mouth 
of the test-tube with the thumb and invert over a small vessel 
of mercury, and set aside in a warm room for several hours. If 
sugar be present, fermentation will occur at once, liberating 
the carbonic acid gas which collects in the upper end of the 
tube, displacing the urine and mercury more or less, according 
to the quantity of sugar present. One precaution should be ob- 
served. Some specimens of yeast spontaneusoly evolve gas, and 
it is, therefore, best to perform a parallel experiment with 
yeast mixed with water, so that the spontaneously evolved gas 
may be estimated." (Purdy, Practical Urinalysis, 1894.) 

Treatment. — Personal hygiene must be carefully enforced, in- 
cluding a moderately active out-of-door life in an equable cli- 
mate, the use of proper underwear, abstinence from everything 
liable to create much bodily fatigue or mental strain, and a bath 
at least every other- day, lukewarm or cold, according to the 
strength of the patient. "Chilling" must be carefully avoided. 

Diet is of prime importance. Sugar and starch must be ex- 
cluded, and fruits and vegetables which are rich in them are 
strictly prohibited. Saccharine, if tolerated, or glycerine may 
be substituted for sugar. Drinks and beverages containing 
sugar, as champagne, lemonade, cider, ginger ale, aerated 
drinks, etc., are positively forbidden. Milk, unless skimmed, is 
also under the ban, and even skimmed milk, recently so popu- 
lar, is now considered injurious. Water should be used freely, 
especially alkaline waters, as Vichy, Londonderry Kthia, Apolli- 
naris, Waukesha, etc.; the ready elimination of sugar demands 
it, and if the patient is denied it, the tissues will suffer corres- 
pondingly. Tea and coffee may be used, but without sugar. 
Bread is highly objectionable, but it is difficult to find a satis- 
factory substitute for it, a majority of the biscuits and breads 
for diabetics being utterly without merit. Almond flour has 
been tried, but bread made from it is heavy and indigestible. 
Bread made from gluten flour is open to the same objections; it 
frequently contains a large percentage (35 to 40, and more) 
of starch, and soon becomes very distasteful to the patient. In 
the majority of cases it is absolutely necessary to allow a few 
ounces of bread daily. The following, from Hare, is a good 
recipe for gluten bread: take one quart of sweet milk or milk- 
and-water, one heaping teaspoonf ul of good butter, one-fifth of 



366 CONSTITUTIONAL DISEASES. 

a cake of compressed yeast beaten up with a little water, and 
two eggs well beaten. Stir in the gluten flour until a soft 
dough is formed, knead as in making ordinary bread, put in 
pans to raise, and when light, bake in a hot oven. — Potato may 
be used in moderation. 

The physician must not be arbitrary in making up the 
dietary or inconsiderate of reasonable demands on part of the 
patient. The needs of each case must be studied and met; sud- 
den radical change is to be avoided and a policy of gradual re- 
striction adopted, removing, one by one, from the dietary such 
articles of food as are especially injurious, with a return to a 
more liberal diet when this is justified by improvement, always 
avoiding carbo-hydrates and encouraging the use of meats. 

The various dietaries suggested are, of course, complicated, 
and many contain articles largely beyond the reach of persons 
of moderate income. Generally speaking, the following list 
will be found useful: 

Forbidden: All starchy foods, sugar, potatoes and bread, 
save as taken with advice of ths physician. Rice, tapioca, 
arrow-root, sago, groats, beans, peas, lentils, chestnuts, tur- 
nips, radishes, and all sweet and dried fruits. 

Allowed in any quantity: Meat (fresh and smoked), tongue, 
ham, bacon, fish, oysters and shell-fish, crabs and lobsters. 
Animal jellies. Eggs, caviare, cheese, butter, pure cream. 
Spinach and cooked salads. Cucumbers, green asparagus, 
water-cress, sorrell, mushrooms, olives, nuts. 

Cauliflower, carrots, cabbage, green beans and berries may 
be used in small quantities. Of beverages, in addition to those 
mentioned, liquors, ices, sorbets, cocoa and chocolate are abso- 
lutely forbidden. Light sour wines may be used freely; un- 
sweetened lemonade may be drunk in small quantities. 

Medicinal treatment is unsatisfactory. Opium is considered 
capable of limiting the progress of the disease, and is given in 
the form of morphia, from four to six grains in the twenty- 
four hours. Diabetic patients not only tolerate large amounts 
of this drug, but do not appear to suffer when it is temporarily 
withdrawn, as it should be when there is an improvement of 
the general condition. Codein has been used as a substitute, 
in the same dose, but morphia is preferred. Complications 
must be treated according to the indications present. For the 



DIABETES MELLITUS. 367 

tormenting eczema and pruritus Osier recommends lotions of 
boric acid or hyposulphite of soda, one ounce to a quart of 
water. Diabetic coma has, so far, proved beyond the reach of 
treatment. Neither inhalations of oxygen nor intravenous in- 
jections of saline solutions (three per cent, solution of sodium 
bicarbonate) have proved of more than slight temporary benefit. 
Homoeopathic literature furnishes proof that the indicated 
remedy may relieve many symptoms and prolong life; some 
cures are also related; but the result of treatment is not satis- 
factory. Of the long list of remedies which have been recom- 
mended from time to time, few have proved of any value. The 
following are the most reliable: Arsenic, Aurum, Bromide of 
arsenic, Creosote, Iodine, Lycopodium, Phosphoric acid, 
Phosphorus, Plumbum, Syzygium, Strychnine, Uranium 

NITRATE. 

Uranium nitrate has been in use since Lecomte (1857) 
stated that dogs poisoned with small doses of it void saccha- 
rine urine; instances of permanent improvement under its exhi- 
bition are given by reliable reporters. It seems to be especially 
useful in cases with derangement of digestion and assimilation. 
It has proved of service in the diabetes of pregnancy. The 
symptoms which indicate it are: dyspepsia, enormous appetite 
and thirst, great abdominal distension, exhaustion and de- 
bility, coldness of the body, and evidence of pancreatic involve- 
ment. The most satisfactory results have been produced by 
the mother tincture in material doses and by the low attenua- 
tions (lx and 2x).— Phosphoric acid corresponds to the ' 'ner- 
vous" type. The introduction of phosphorus into the system 
is followed by the excretion of saccharine urine, and the drug is 
closely related to those conditions of great nervous depression, 
grief, worry, etc., which figure among the important setiological 
factors of diabetes. "Urine like milk, mixed with jelly-like bloody 
mucus, or clear, like water; pain in the back and region of the 
kidneys; sleeplessness; excessive emaciation; great prostration;" 
flaccidity of the genital organs; sexual appetite gone, or weak 
and premature emissions, followed by great prostration; after 
the loss of animal fluids, fast living, grief, disappointments, 
etc.— Arsenic is not used as often as its merits deserve. Its 
action upon the liver, seriously interfering with its glycogenic 
function, and upon the kidneys has lead to its occasional and 



368 CONSTITUTIONAL DISEASES. 

reasonably successful exhibition. Its restlessness, anaemia, pro- 
found prostration, melancholia (accompanied with nervous 
tension), albuminuria, dryness of the skin, scaly, scurfy erup- 
tions, carbuncles with shooting, burning pain, neuralgic affec- 
tions (sciatica), — all these are symptoms of frequent occurrence 
in diabetes. In gangrenous conditions, such as may occur here, 
it needs to be carefully considered. In three cases under my ob- 
servation the remedy did excellent work; one of the patients is 
still living, and is actively engaged in business, apparently well. 
The liquor arsen. brom. is a favorite prescription with some 
physicians; Hale recommends the arsenite of iron (2x tritura- 
tion) when there is anaemia or malarial cachexia; he also cites 
Purdy, who claims good results from T \ to \ of a grain. Of 
late a combination of arsen. brom. with gold has been much 
employed.— Phosphorus is suggested by its close relation to 
the pancreas, liver, kidneys and lungs, and by its power to set 
up a general neuritis. There is great exhaustion of body and 
mind, with irritability of the nervous system. The urine is 
milky white, containing fatty casts. There is burning heat in 
the stomach, extending to the back, with faintness and a sense 
of emptiness in the stomach and bowels; atonic dyspepsia; re- 
lief of gastric S3'mptoms from drinking cold water, with subse- 
quent aggravation, even to vomiting, as soon as the water has 
become warm in the stomach. Pulmonary complications.— 
Plumbum is of service when there is albuminuria. Periodic at- 
tacks of vomiting food, with gastralgia and enteralgia, relieved 
by hard pressure. — Iodine is an important remedy in affections 
of the pancreas, and is occasionally useful here when pancreatic 
symptoms are prominent, even though it does not completely 
cover the urinary symptoms. It has the ravenous, insatiable 
hunger, with progressive, extreme emaciation in spite of the 
large amount of food taken; despondency, great peevishness 
and irritabilit}^; fat in the stools; skin dry, brown, rough. 
"Scrawny" appearance of the patient. Pulmonary involve- 
ment with characteristic symptoms. 

Among other remedies which have been found serviceable are: 
Syzygium, which at one time was used extensively and, it 
seemed, with good results, in doses of from three or five to 
thirty grains of the pulverized seeds three times per day. More 
recent experience has shown that it is not reliable in its action, 



DIABETES INSIPIDUS. 369 

and that large doses may greatly lessen the amount of urine 
without diminishing the amount of sugar.— Kreasotum, ac- 
cording to Hale, is credited with some cures that seem perma- 
nent. "I very nearly cured a case with ten drops of the first, 
four times a day. The sugar was reduced to five grains to the 
ounce, when the patient left the city and has not reported 
since." — Asclepias vinetoxicum is said to have caused in sheep 
fed upon it a form of diuresis with violent thirst, and to have 
greatly reduced in a number of diabetics the sugar present in 
the urine. Consult also: Rhus aromat., Sodium salicylate, 
Terebinthina, LYCOPODraM, Leptandra, Iris, Podophyllum, 
Nux vomica, Arnica, and Natrum sulphuricum. 

Rockwell reports marked benefit derived in one case, com- 
plicated with locomotor ataxia, from general faradization al- 
ternated with central galvanization. 



DIABETES INSIPIDUS. 

Diabetes insipidus, also known as polyuria, hydruria, poly- 
dipsia, hyperuresis, is a constitutional disease characterized by 
passages of large quantities of non-saccharine urine of low spe- 
cific gravity. 

Etiology. — It occurs oftenest in persons in early life, from the 
tenth to the twenty-fifth year, and rarely after middle life; it is 
less frequently seen in young children, and only exceptionally in 
those of advanced years. It is more common in persons of the 
male sex than in females. Heredity is an active factor; the affec- 
tion has been observed for three and four generations in the same 
family, at times alternating with saccharine diabetes. Its 
most fruitful cause seems to be a violent shock to the nervous 
system, as a severe fright or an overwhelming emotion, intoxi- 
cation with alcohol (or lead), traumatism (head, trunk, limbs), 
sunstroke, etc. Occasionally it occurs during convalescence 
from a severe fever or other acute illness, or in connection with 
cerebral affections (tumors of the brain, lesions of the medulla, 
tubercular meningitis, paralysis of the sixth nerve), or with se- 
rious abdominal diseases, such as abdominal tumors (Dickin- 
24 



370 CONSTITUTIONAL DISEASES. 

son), abdominal aneurism (Ralfe), or tuberculous peritonitis 
(Osier). 

The essential nature of the disease is unknown. It probably 
is of nervous origin, vaso-motor disturbances of the renal ves- 
sels resulting from nervous influence. There are no character- 
istic anatomical changes. 

Symptoms.— The development of polyuria may be rapid in 
cases which arise from fright, violent agitation, or powerfully 
acting moral cause. Usually it develops slowly. The chief 
symptoms consist of the frequent emission of large amounts 
of urine, varying from 15 or 20 to 40 pints daily, of low spe- 
cific gravity (1.001 to 1.005), watery, colorless, of acid reac- 
tion when fresh, but neutral or alkaline after standing. The 
relative amount of solids in the urine is lessened, but the sum 
total of solids passed during the twentj'-four hours is ma- 
terially increased. Thirst naturally keeps step with the 
amount of liquid passed off. There is scanty secretion of saliva, 
great dryness of the mouth, the tongue becomes red and glazed, 
and occasionally a fall of the bodily temperature below normal. 
The appetite in many cases remains good, digestion and assim- 
ilation active, and the patient appears and feels well and 
hearty. In more serious cases the digestion becomes deranged, 
and headache, dizziness, emaciation, loss of physical and men- 
tal energy, with various nervous disturbances, are experienced, 
the condition in some instances bearing a close resemblance to 
saccharine diabetes. When polyuria occurs during childhood, 
it is liable to interfere with proper growth and development of 
the little patient. Pulmonary affections, paralysis of the sixth 
and other cranial nerves, loss of reflexes and diseases of the eye 
(retinal haemorrhage, neuro-retinitis, atrophy of the optic 
nerve) constitute complications in grave and advanced cases. 

The course of diabetes insipidus depends somewhat upon the 
nature of the cause. If idiopathic, it may run on indefinitely, 
death eventually occurring from some intercurrent malady or, 
much more rarely, a cure taking place spontaneously. If result- 
ing from a deep-seated or organic disease, we find the grave 
manifestations already described, with death usually from ex- 
haustion, convulsions and coma, or from pulmonary complica- 
tions. In these serious cases there is a loss of urates as the di- 
gestive powers become impaired. At intervals, sugar may be 



DIABETES INSIPIDUS. 371 

found in the urine; traces of albumin may be detected; urates 
and oxalates may be present in large amounts, especially in 
children and young persons; an excess of phosphates accom- 
panies disturbances in the nervous system and pulmonary 
complications. 

Diagnosis. —The diagnosis from saccharine diabetes rests 
upon the absence of sugar from the urine, its low specific 
gravity, and the character of the constitutional symptoms. 
The polyuria of hysteria may be recognized by the history of 
the case, the transient character of the urinary symptoms, and 
the nature of the concomitants. 

Treatment. — The general treatment consists of such measures 
as will place the patient in the best possible hygienic surround- 
ings. No particular restrictions as to diet are necessary, save 
abstinence from such articles of food as have proved deleteri- 
ous. Water may be drunk ad libitum; possible benefits from 
limiting the amount of drink taken are more than offset by the 
resulting tormenting thirst and the annoyance arising from it. 
Acidulated drinks are especially grateful. Hot baths and fre- 
quent rubbing are beneficial; the electric current (galvanism) 
may prove advantageous. Antipyrine (fifteen grains every 
four hours) has become a standard remedy; valerian in large 
doses (one ounce of the extract, in divided doses, during the 
twenty-four hours) and ergot (one-half drachm to one drachm 
of the fluid extract three or four times daily) are highly recom- 
mended by leading clinicians of the dominant school. 

Phosphoric acid is of great service in those exhausted con- 
ditions of the nervous system to which reference has been made 
in the preceding chapter. The urine often is thick and milky, 
and there is frequently copious and persistent diarrhoea, which, 
however, does not exhaust the patient.— Natrum muriaticum. 
Copious emissions of pale, limpid urine; great thirst, despon- 
dency, physical and mental exhaustion, anaemia, marasmus. 
Weakness and sinking at the stomach. Involuntary emission 
of urine from sneezing or coughing. Violent palpitation of the 
heart, shaking the whole body. Paralytic tendency. Charac- 
teristic eruptions with much itching and smarting, with acrid, 
irritating discharges and formation of crusts. — Helonias. 
Large quantities of clear, light-colored urine of low specific 
gravity, with much debility and emaciation. Constant aching 



372 CONSTITUTIONAL DISEASES. 

and tenderness oyer the kidneys. Languor, drowsiness. — Se- 
cale, by the dominant school, is given for its physiological 
effects. Its use, homceopathically, is suggested by great ner- 
vous exhaustion, with tendency to numbness, anaesthesia, par- 
alysis, or to gangrenous affections. Internal heat and exter- 
nal coldness, with unwillingness to be covered; restlessness; de- 
sire for sour drinks; severe watery, gushing diarrhoea.— Scilla 
has been highly recommended, especially by Hughes. Its 
provers experienced interesting urinary symptoms, as: inability 
to retain the urine because the amount was too large; it would 
have been passed involuntarily if he had not hastened. Waking 
at night to urinate. Urine as clear as water. — Iodum, with the 
indications given under saccharine diabetes. Pulmonary com- 
plications. 

Taking into consideration the probably nervous origin of the 
disease, it is evident that among the important remedies must 
be placed Ignatia, Valeriana, Zincum valerianicum, Aurum, 
Pulsatilla, and others of the same class, their exhibition de- 
pending not so much upon the urinary symptoms presented as 
upon the general characteristics of the case. In the same man- 
ner Arnica may be suggested by traumatic origin of the affec- 
tion. Rhus aromatica, Causticum, Glonoine, Terebinthina 
and Apis should also be studied. 



RICKETS. 

A disease of infancy, characterized by impaired nutrition and 
alterations of the growing bone (excessive proliferation and 
deficient calcification), accompanied with general constitu- 
tional weakness, anaemia, laxity and weakness of the muscles, 
great susceptibility to catarrhal inflammation of the respir- 
atory and gastro-intestinal mucous membrane, and pronounced 
reflex irritability with tendency to laryngismus and tetany. 

^Etiology. — The essential cause of rickets is not known. It 
occurs oftenest in large cities among the children of the poor, 
who live in poverty and filth, and suffering from the lack of 
sunshine, fresh air and proper food. It is very common in 
European countries, and until recently had been thought rather 



RICKETS. 373 

infrequent in America. Continued excessive immigration and 
the rapid growth of American cities, with their attendant evils, 
have rendered the disease much more common than formerly in 
this country, as abundantly proved by reports from public hos- 
pitals and dispensaries in the large American towns. The negro 
race are said to be especially liable to rickets. 

Among the well-to-do, rachitis is seen chiefly in children who 
have been kept too long at the mother's breast or who have 
been fed on artificial food containing an excess of starch and a 
deficiency of fat. 

The disease occurs in early infancy. J. Lewis Smith shows 
that out of a total of 903 cases of rickets, 99 occurred during 
the first half year of life; 259 during the second half year; 342 
during the second year; 134 during the third year; 31 during 
the fourth year; 17 during the fifth year; 21 between the fifth 
and ninth year. 

Predisposing causes consist of any influence exerted upon the 
child in utero or after birth which enfeebles digestion and as- 
similation or materially weakens the general tone of the sys- 
tem. Thus, children suckled during pregnancy of the mother, 
or breast-fed when the mother's milk has ceased to be nourish- 
ing, or who inherit tubercular or syphilitic taint, or whose vi- 
tality is lowered from any other cause, frequently become 
rickety. Occasionally, new-born children bear all the marks of 
the disease; they are still-born or die soon after birth. 

Morbid Anatomy.— The bones of the body undergo remarka- 
ble changes, especially noticeable at the epiphyses of the long 
bones and at the ribs. The seat of the affection is the prolifer- 
ating zone of the long bones, which in the normal bone is very 
thin, consisting of a "scarcely perceptible layer of a reddish- 
gray color upon the end of the shaft." In rickets this zone con- 
sists of many layers; cell proliferation is maintained at an ex- 
cessive rate, and the proliferating zone itself appears as a soft, 
grayish, translucent cushion, with corresponding enlargement 
of the part. With these changes the formation of bone is ar- 
rested or made abnormal, lacking in both natural rapidity of 
development and firmness of texture. Chemically, there is a 
great deficiency in lime-salts. 

The poverty of earthy matter renders the bone soft and easily 
yielding to pressure, hence the curvature of long bones in 



374 CONSTITUTIONAL DISEASES. 

rickets from inability to sustain the weight of the body. Other 
manifestations of morbid action here are the "rachitic rosary," 
due to the swelling of the anterior ends of the ribs; craniotabes 
or thinning and softening of the cranial bones; affections of the 
vertebrae, resulting in spinal curvature; deformities of the 
pelvis, etc. 

Eventually, reparative processes take place. Pressure upon 
the enlarged portions of bone by the tightly drawn periosteum 
gradually lessens the hyperaemia and exudation, while new 
matter, rich in lime salts, is deposited in the concavities and 
forms exceedingly hard layers of osseous formation, resembling 
tooth-enamel and usually described as "eburnation." The hy- 
peraemia constantly lessening, the proliferation process event- 
ually becomes normal, the texture of the bone permanently in- 
creases in firmness, the soft parts regain their vigor, and more 
or less complete recovery takes place. Enlargement of the liver 
and spleen as the result of cell proliferation has been observed 
in from 30 to 35 per cent, of cases examined after death. 

Symptoms. — The first symptoms of trouble usually occur 
during the period of dentition. The child "droops," becomes 
irritable and cross, and restless both day and night. Digestion 
is deranged. Appetite is fitful, often craving; there is vomiting, 
diarrhoea of sour, undigested stools, or constipation; some- 
times periods of diarrhoea alternate with constipation. The 
little patient is more or less feverish; he shows an unwilling- 
ness to exert himself or even to be handled, and it is readily seen 
that every touch of the body, whether on bony structure or 
soft parts, causes suffering. At night he sweats profusely 
about the head and neck, often completely soaking the pillow. 
Usually this condition is accompanied by considerable loss of 
flesh; but often a reasonable degree of plumpness of the body is 
preserved. If the child is old enough to walk, the soreness of the 
body from touch or motion makes him desist; he prefers to lie 
quiet, and if he undertakes to move at all, it is done feebly and 
with unsteadiness of motion. As the case progresses, the soft 
tissues become more and more flabby, the skin grows pale and 
often is covered with miliaria, and the lack of power in the ex- 
tremities may be sufficient to excite fears of paralysis. 

In the meantime, the characteristic bone lesions have begun, 
with swelling about the epiphyses of the long bones, generally 



KICKETS. 375 

first noticed about the wrist. Nodules, which may readily be 
felt and seen, are formed at the junction of the bone and car- 
tilage, in the ribs giving rise to the rachitic rosary, a symp- 
tom which does not appear until after the third month, grad- 
ually increases up to the second year, and disappears during 
the fourth year. The shape of the thorax is affected by the 
softening of the ribs, forming the so-called "pigeon-breast," the 
result of abrupt bending of the ribs, chiefly from atmospheric 
pressure during respiration, lessening of the transverse diame- 
ter of the anterior half of the chest, and subsequent marked 
prominence of the sternum, particularly in its lower half. 
"Harrison's groove" is a transverse curve from the level of the 
ensiform cartilage toward the axilla. Breathing becomes 
somewhat abnormal in that there is a considerable sinking of 
the chest on each side during inspiration. These changes 
naturally affect the integrity of the lung, and, owing to the 
susceptibility of the respiratory mucous membrane, there is in 
all these cases a great liability to bronchitis and broncho- 
pneumonia. Curvature of the spine, usually antero-posterior, 
sometimes lateral, is common; it is due to the weight of the 
head and shoulders upon the softened vertebras. In some severe 
cases the vertebras are not involved and there is no curvature. 
The shape of the head is abnormal in a majority of cases. It 
usually presents a square shape (caput quadra turn; tete 
carree), and appears very large in proportion to the upper por- 
tion of the body and neck, the result of thickening of the fron- 
tal bone, causing protrusion of the forehead, and of the parietal 
eminences. The fontanelles remain open for a long time, some- 
times as late as the fourth year, and there is thinning of por- 
tions of the skull, which is due to softness of the bone, to pres- 
sure of the brain from within and of the pillow from without. 
To this condition the term craniotabes is applied. Craniotabes 
is oftenest found in quite young children, less than one year of 
age, and is seen in the occipital and posterior half of the parie- 
tal bones. There may be mere thinning of the bone or com- 
plete absorption over a considerable area. In examining for 
craniotabes pressure should be applied away from the sutures 
and should be made with care, so as not to injure the underly- 
ing, sensitive brain substance. It must also be remembered that 
neither craniotabes nor the disfigurement of the thorax are in 



376 CONSTITUTIONAL DISEASES. 

themselves positive evidence of rickets. The former may occur 
in inherited syphilis, and the changes in the thorax may be 
caused by any condition which prevents the free entrance of 
air into the lungs. The bones of the face are often stunted; the 
lower maxillary bones may assume a polygonal shape, with an 
inclination forward of the alveoli and softening, lengthening of 
the upper maxillary from the zygomatic arch forward, thus 
changing not only the shape of the arch, but the position of the 
teeth, so that the latter no longer properly antagonize each 
other. Dentition is late in appearance, and the teeth usually are 
small and badly formed. In the bones of the upper limbs the 
changes which take place are less pronounced than in the legs, 
since the arms support less weight, except as the patient, in 
crawling about on the floor, may get the habit of sustaining 
himself by the upper limbs. Swelling of the lower end of the 
radius is, however, one of the earliest signs of rachitis, and 
both radius and ulna may be bent and twisted. The humerus 
may be bent from the action of the deltoid muscle. The clavi- 
cle may be thickened, usually at its sternal end; the scapulas 
are occasionally thickened at the margins. In the legs the 
curvatures are more pronounced than in the arms because of 
the great weight which they are called upon to support. En- 
largement of the tibia at its lower end appears early; in severe 
forms its upper extremity and the fibula and femur are also in- 
volved. The kind of curvature induced varies greatly; some- 
times it is extreme, J. Lewis Smith citing "an anterior curva- 
ture so abrupt that an angle of 70° was formed about five 
inches above each ankle." Affections of the bones of the pelvis 
are very serious when they occur in girls; narrowing of the 
outlet of the pelvis is usually produced, thus, later in life, giving 
rise to grave complications during labor. 

While these changes are taking place in the osseous system, 
the child continues to suffer from restlessness, feverishness, ten- 
dency to sweat, especially about the head, and perseveres in its 
unwillingness to sleep under cover during the night, regardless 
of the temperature of the room. 

The soreness and tenderness to touch all over the body grow 
worse rather than better. Indigestion persists, with periods of 
diarrhoea or constipation. The child refuses to make use of 
arms or legs, and seeks to rest quietly on the pillow in the most 



RICKETS. 377 

comfortable position. If craniotabes be present, it prefers to 
be held so the head rests over the shoulder of the nurse, by this 
means avoiding pressure upon the brain which disturbs the 
cerebral circulation and causes pain, irritation and restlessness. 
The possibility of more serious trouble in cases where by the 
existence of extensive craniotabes the brain is deprived of its 
natural protection is, of course, evident. The close relation, for 
instance, between this condition and dangerous spasm of the 
glottis has been amply demonstrated; the peculiar habit of such 
patients of "holding their breath" until the attendants are 
thoroughly alarmed is also of neurotic origin. On the other 
hand, it is a noteworthy fact that the intellectual activity of 
these children is very marked, probably because of the freedom 
of the brain from restriction from without. Many rickety chil- 
dren display a surprising degree of brightness, and it is on this 
account, and the often resulting dwarfed growth, that this 
class of persons furnished a majority of the jesters and court 
fools of medieval times. 

Eclampsia sometimes occurs during the course of the disease, 
and tetany is occasionally seen. These often depend upon gas- 
trointestinal or respiratory catarrh or intestinal irritation; 
exceptionally they are of purely nervous origin. Great abdom- 
inal enlargement is frequently found, due to flatulent distension 
and to enlargement of the liver and spleen; the shape of the 
thorax increases the impression of excessive abdominal protu- 
berance. 

Diagnosis. — The diagnosis of rickets should not be difficult. 
Jenner attached especial importance to the general soreness and 
tenderness to touch which creates the desire to remain still; 
to the tendency at night to throw off the bed covering, and to 
the copious sweating of head and neck, soaking the pillow. 

Prognosis. — The prognosis is good, as to life. In almost all 
cases partial recovery takes place, save as complications, such 
as bronchitis, broncho-pneumonia, laryngismus stridulus or 
convulsions suddenly cause a fatal termination. However, a 
certain arrest of normal growth, even after recovery from the 
rachitis, is a common feature, often leaving the victim of the 
disease much below the average stature. This is said to apply 
with particular force to cases beginning at a very early period 
of infancy. 



378 CONSTITUTIONAL DISEASES. 

Treatment. — With a full understanding of the conditions 
most unfavorably affecting pre-natal life, the intelligent physi- 
cian will do all in his power to insure the best possible health 
on part of the pregnant mother, thus protecting both mother 
and child. The double drain of "carrying" one child and suck- 
ling another must be avoided, and the mischief resulting from 
rapidty repeated pregnancies will be lessened by extra care in 
providing rest, sunshine, open air, healthful surroundings, and 
an abundance of good food to the mother and, in due time, to 
the child. These precautions are truly prophylactic. 

As soon as symptoms of rachitis show themselves in the 
young child, energetic measures must be taken to arrest the 
disease, and intelligent treatment here often proves surprisingly 
successful. The first and chief thing to be done is to provide 
suitable diet. If the child is at the mother's breast, the appear- 
ance of rickets is strongly presumptive proof that the mother's 
milk is deficient, and a good wet-nurse should be provided at 
once or cow's milk be substituted. If neither agree, artificial 
food must be tried. To provide suitable food is not only of the 
last importance, but, as physicians realize, is at times a task 
demanding great patience, close observation, and good judg- 
ment. Generally speaking, farinaceous substances are to be 
avoided and fats supplied with liberality. The stools must be 
watched closely, and whenever they show evidence of indiges- 
tion, or vomiting is at all persistent, a change must be made, 
the physician feeling his way until he has by actual trial deter- 
mined what best agrees with the child. In the majority of 
cases, cow's milk, properly diluted, is to be preferred to artifi- 
cial foods. The addition of barley-water or well-strained oat- 
meal gruel is to be recommended. Fresh beef -juice or scraped 
lean meat often acts well. 

Bathing in tepid water is important and should be practiced 
dairy, provided due care be taken not to have the child handled 
roughly nor allow it to take cold. Rickety children are sensi- 
tive and do not always react well; hence the room in which the 
bath is given should be absolutely free from draughts and kept 
at a temperature of not less than 75°. A daily sponge bath, 
gently administered, is helpful. The child must be held in the 
lap of the nurse, on a rubber sheet protected by a soft dry 
woolen blanket, the bath being given quickly and followed by 



RICKETS. 379 

gentle friction. Daily bathing in olive oil or cod-liver oil is also 
very serviceable, and often indispensable. The importance of 
proper clothing, of keeping the feet warm, of maintaining ab- 
solute cleanliness, and of spending as much time as possible in 
the sunshine and in the open air is self-evident. 

To avoid deformities, it is well to keep the patient perfectly 
quiet, especially to allow no attempts at walking; splints may 
be used as supports if for some reason absolute rest seems not 
necessary; if the splints are extended beyond the feet, they ren- 
der walking impossible. 

Therapeutics.— Calcarea carbonica, Calcarea phosphor- 
ica, Phosphorus and Silica are sufficient for the cure of the 
great majority of cases. 

Phosphorus holds a close relation to tht osseous tissue, and 
in its action upon the healthy causes symptoms which bear a 
striking similarity to rickets; it is therefore not surprising that 
its exhibition, even empirically, yields very satisfactory results. 
The dominant school prescribe it in doses of T ^o to T 4- T of a 
grain, dissolved in olive oil, three times daily. Even better ef- 
fects are obtained from still smaller doses thoroughly subdi- 
vided.— Calcarea carbonica acts upon the bony structure, 
has slowness of growth, tardiness of teething, late closing of 
the fontanelles; it also has copious sweating about the 
head, cold feet, great weakness, indigestion, diarrhoea, some- 
times constipation. Remarkable distension of the abdomen 
("pot-belly") is one of its best and most reliable characteristics. 
— Calcarea phosphor, is the favorite preparation of many 
physicians, possessing, it is claimed, the curative powers of the 
lime and phosphorus combined. The diarrhoea here is rather 
more aggressive and the symptoms of indigestion more 
marked. Vomiting is very persistent; there is more flatulence, 
and the abdomen, though large and full, is more lax and flabby 
than under Calc. carbon. The sensitiveness to dampness which 
is peculiar to Calcarea is here strongly marked, and aggrava- 
tions from exposure to it occur constantly. Iodide of lime is used 
less often, but has done excellent work. — Silica closely resem- 
bles Calcarea, but the is pronounced dryness of the body with 
copious and sour sweating about the head; the abdomen is 
large, but sunken-in rather than distended; there is much ema- 
ciation of the body, but it is not soft and flabby; the child ap- 
pears "scrawny;" tendency to indurations. 



380 CONSTITUTIONAL DISEASES. 

This small list embodies the very best of the therapeutics of 
rickets. It is only exceptionally that other remedies will be re- 
quired by special and, usually, transient symptoms. Thus, 
Kali phosphor, (atrophy of the bones, with putrid smelling 
discharges from the bowels. — Bcericke & Dewey), Natrum mu- 
riaticum (thighs very much emaciated; slight pliability of the 
bones.— Gilchrist), or Kali hydriodicum (enlarged glands, 
swelling of bones, hard lumps on cranium, decaying teeth, jerk- 
ing or contracting tendons, great emaciation and tenderness of 
the entire body, extremely irritable and fretful. — E. C. Frank- 
lin), may be called for.— Pulsatilla, Chamomilla, China, 
Phosphoric acid, Mercury and others, may meet gastro- 
intestinal symptoms which demand attention.— Fluoric acid, 
when there is suspicion of syphilitic taint. — Baryta carbonic a 
when there are indurations of the glands of the neck and 
throat, especially of the tonsils; voracious appetite, yet emaci- 
ation; the child appears dwarfed mentally. — Arsenicum, with 
its characteristic debility and restlessness, its scorbutic ten- 
dency and important gastro-intestinal symptoms, is occasion- 
airy demanded. 

Cod-liver oil has been urged as an excellent food and remedy. 
H. H. Purdy, of New York, in a series of about eighty cases ob- 
tained under its use better results than he had from Phos- 
phorus alone. 

Complications are treated as they arise. 



SCURVY. 

Scurvy (scorbutus) is a constitutional disease characterized 
by great debility, spongy condition of the gums, and hasmor- 
rhagic diathesis with effusion of blood chiefly into the skinj but 
often into the muscles, joints, and mucous membranes. 

Etiology.— At one time scurvy was one of the commonest 
diseases with a large mortality record, appearing constant^ in 
armies, among the inhabitants of invested cities, and among 
the crews of ships on long voyages; modern investigation, by 
determining the conditions under which it appears, has ren- 
dered the affection comparatively rare. It still occurs, either in 



SCURVY. 381 

isolated cases or endemically in prisons, almshouses, etc., nearly 
always from mismanagement and criminal neglect of duty on 
part of the officials. 

It is conceded that the cause of scurvy lies in improper 
dietetic conditions, namely: a lack of variety and probably 
want of fresh vegetables. All attempts, so far, to fix the re- 
sponsibility upon the absence from the food of some one partic- 
ular element, as the potassium salts, have been unsuccessful. 
Experience has demonstrated that the free use of the juice of 
the lime or lemon and of vegetables is an almost positive means 
of preventing scurvy; few ships, therefore, now start on a long 
voyage without being amply provisioned with these articles, 
an act of caution which in America, at least, has been made 
obligatory. 

Physical and moral influences of a depressing character are 
factors of some importance. Poverty, living in damp, unhealth- 
ful quarters, exposure to great cold or heat, undue fatigue, 
and the use of bad food are to be mentioned in this connection; 
also, imprisonment, homesickness, and other depressing influ- 
ences. Age and sex seem to have no bearing. Very young chil- 
dren and old people may have scurvy. Leduc, for instance, 
records the case of a man who had always lived well, becom- 
ing a scorbutic at the age of seventy-two years. 

Symptoms. — The premonitory symptoms, which may con- 
tinue for several days or a week, are languor, debility, pallor, 
palpitation of the heart, and an aching, dragging pain in the 
loins and legs; the patient takes to his bed, appears indifferent 
to his surroundings, and is very sensitive to cold. The charac- 
teristic symptoms then appear: the scorbutic condition of the 
gums and the haemorrhages, occurring simultaneously or one 
preceding the other. The gums assume a bluish color, swell, 
become spongy, and bleed easily. This condition is most 
marked between the teeth; where teeth are absent, as in the 
very young or very aged, the gums are affected slightly, if at all. 
The teeth become loose and fall out. Superficial necrosis is not 
uncommon and may involve the deeper tissues, giving rise to 
dirty-looking, foul ulceration; this process may extend and 
cause a diffuse ulcerative stomatitis. The breath then becomes 
exceedingly foul. The tongue may be swollen, red, only 
slightly furred, with, in some cases, swelling of the salivary 



382 CONSTITUTIONAL DISEASES. 

glands; sore throat may be present in the early history of the 
case. 

The hasmorrhagic diathesis shows itself chiefly in hemor- 
rhagic effusions of the skin, first, of the legs, then arms, then 
trunk. Large dark-red spots appear, differing in size, assuming 
a bluish color, shading into green or yellow at the periphery, 
much like the "black-and-blue" spots which result from a bump 
or fall. These ecchymoses do not often occur on the face or 
scalp. Sloughing of the skin and deep ulceration is seen in se- 
rious cases, and constitutes a grave complication. The deeper 
tissues may be involved, as the subcutaneous connective tissue, 
muscles or periosteum. In aggravated cases effusion may take 
place between the periosteum and bone, giving rise to the forma- 
tion of nodules which may break down and form sores; the parts 
thus involved are usually painful and tender to the touch. 

Epistaxis is a common symptom, but there are rarely haem- 
orrhages from the mucous surfaces except from the gums, 
stomach or internal organs; in severe cases there may be bleed- 
ing from the stomach, intestines, bronchi, kidneys, and effusion 
into the serous membranes. 

With these symptoms there is rapidly increasing debility, 
pallor and dryness of the skin, and emaciation. The tempera- 
ture is normal, sometimes below normal, save as it is raised by 
some existing complication. The heart beat is irregular, feeble, 
and compressible. The appetite is poor, and attempts to eat 
are rendered painful by the soreness of the gums and mouth. 
The bowels usually are constipated, sometimes loose. The 
urine is dark, of high specific gravity, often contains albumin, 
and sometimes an increase of phosphates. Enlargement of the 
spleen is comparatively frequent. There is mental depression 
and headache, with, in exceptional cases, such severe symp- 
toms as delirium, convulsions, hemiplegia, apoplexy. Osier 
mentions the occasional occurrence of night-blindness and day- 
blindness. 

Severe cases may be complicated by bronchitis, lobular and 
lobar pneumonia, or involvement of the articulations; there 
may be hemorrhagic or serous effusions; endocarditis is rare. 

The blood is dark fluid and shows no specific changes under 
the microscope. After death the spleen has been found en- 
larged and soft, with changes also in the parenchyma of the 
liver, heart and kidneys. 



scurvy. 383 

A special form of scurvy in young rickety children is recog- 
nized ("acute rickets"), of which sometimes hematuria is the 
only symptom. This condition closely resembles rickets; a dif- 
ferentiation between the two is important in order to deter- 
mine the proper treatment. Barlow points out the following 
features as characteristic of the scurvy, of infants: "(1) Pre- 
dominance of lower limb affection: (a) immobility, going on to 
pseudo-paralysis; (b) excessive tenderness; (c) general swelling 
of lower limbs; (c?) skin shiny and tense, but seldom pitting, 
and not characterized by undue local heat; (e) on subsidence, 
revealing a deep thickening of the shaft; (/) liability to frac- 
ture near the epiphyses. 

"(2) Swelling of the gums, varying from definite sponginess 
down to a vanishing point of minute transient ecchymoses. 
These constitute the chief diagnostic differentia between infan- 
tile scurvy and rickets, properly so-called. But to them must 
be added as the most important diagnostic of all, (3) definite 
and rapid amelioration by antiscorbutic regimen." 

As indicated by Barlow, infants suffering from this affection 
show remarkable improvement under appropriate diet; they 
are very fond of the juice of oranges, and eagerly suck them 
when offered. 

Diagnosis.— The diagnosis can be difficult only when one of 
the two important clinical symptoms— the scorbutic condition 
of the gums or the haemorrhagic tendency — is imperfectly devel- 
oped; such instances are exceptional. The rapid improvement 
of scurvy under antiscorbutic regimen is to be remembered. In- 
cipient or imperfectly developed cases often occur in the army; 
these may lack the important diagnostic signs and go unrecog- 
nized, but they recover rapidly from rest and temporary change 
of surroundings and diet. When scurvy occurs as an epidemic, 
or among an aggregation of persons, a mistake in diagnosis 
will scarcely be made. 

Treatment. — The patient must at once be placed under the 
most favorable hygienic surroundings, -with an abundance of 
fresh air and a suitable diet. The latter should aim not merely 
at a free supply of fresh vegetables, even though some of these, 
like the cochlearia officinalis, have a great reputation as anti- 
scorbutics, but should above all aim at variety. This point 
cannot be too strongly emphasized. Experience has amply 



384 CONSTITUTIONAL DISEASES. 

demonstrated the great usefulness of the juice of lime and 
lemon, hence the patient should be directed, from the very be- 
ginning, to take the juice of two or three lemons daily. When 
there is much weakness and the stomach is irritable, scraped 
meat may be added to the dietary. This treatment alone is 
quite sufficient for the average case. 

In severe cases the same general rules are to be followed and 
the indicated remed}' faithfully administered. 

Special sj^mptoms may demand particular attention. Thus, 
if the gums and mouth are in bad shape, they should be 
cleansed often, thoroughly, and with gentleness. The use of 
mild astringents as a wash for the mouth is indicated in such 
cases. Sage-tea, solution of chloride of potassium or of per- 
manganate of potassium, diluted carbolic acid, tincture of cal- 
endula or of hydrastis in water are very useful for this pur- 
pose. The gums may be painted with the tincture of myrrh or 
with a fairly strong solution of nitrate of silver. If there is ob- 
stinate constipation, copious enemata may be used. Cautious 
massage has been recommended to hasten the absorption of ec- 
chymotic spots. 

Therapeutics.— Arsenic: great debility; nervous tension, 
restlessnesss; despondency; great thirst, the patient wanting 
small draughts of water every few minutes; offensive diarrhoea; 
fetor from the mouth; violent tearing pains, worse about mid- 
night, better from the application of warmth. — Phosphorus: 
hemorrhagic diathesis very marked; ulcerations bleed easily; 
haemorrhage from internal organs; surface pale and cold; fre- 
quent fainting. — Mercury: gums are spongy and bleed much, 
pale blue and receding from the teeth; ulcers on the legs; legs 
swollen; bones ache severely; tendency to the formation of un- 
healthy ulcers on the skin.— Kreosotum: odor from the mouth 
is cadaverous; stools cadaverous; haemorrhage dark, the blood 
coagulating easily; patient exceedingly weary and bruised all 
over; disposition sad and irritable; putrid, acrid leucorrhcea. — 
Muriatic acid: persistent epistaxis; sensitive ulcerations on 
the legs, with burning pain about their circumference. — Carbo 
vegetabilis: excessively low state, with marked tendency to 
bleed from the mucous surfaces (haematuria, menorrhagia, 
haemopt3'sis) and to ulcerations. Flatulency; pallor; coldness 
of breath.— Agave Americana is recommended by Deschere in 



PURPURA. 385 

infantile scurvy with "pale, dejected countenance, gums 
swollen and bleeding; legs covered with dark, purple blotches; 
legs swollen, painful, and of stony hardness; appetite poor; 
bowels constipated; pulse small, feeble." 

Consult also: Natrum muriaticum (exceedingly despondent, 
but does not like to have consolation offered him); Lachesis, 
Kali muriaticum, Kali phosphoricum (sepsis, discharges ex- 
ceedingly foul); Sulphuric acid (aphthous condition of gums 
and mouth; debilitating diarrhoea; dark haemorrhage from all 
the outlets of the body); Ammonium carbonicum (intestinal 
haemorrhage); Secale cornutum (intestinal haemorrhage; cold 
ness of the body, but will not keep covered up); Sulphur, 
China. 



PURPURA. 

Under this general heading are grouped a variety of morbid 
conditions characterized by the spontaneous effusion of blood 
into the skin, mucous membranes or internal organs, and ac- 
companied by local and constitutional disturbances which 
vary with the character and extent of the haemorrhage. 

Haemorrhagic effusions into the skin are most frequent. 
These may be minute, resembling the bite of a flea, but lacking 
the central point of the puncture, and are then called petechiae, 
or they may attain considerable size, when they are called ec- 
chymoses; occasionally they are seen in streaks, when the term 
"vibices" is applied to them. Exceptionally the haemorrhagic 
effusion finds its way into the sweat glands, giving to the per- 
spiration a haemorrhagic tinge, a condition described as haema- 
tidrosis. 

In appearance the petechial and ecchymotic spots are of a 
bright-red color, growing livid blue, then brownish. They do 
not disappear under pressure. 

The cause of purpura is not known. Its occurrence under a 
great variety of conditions — as scurvy, rheumatic affections, 
erythema exudativum, infectious diseases (measles, small-pox, 
etc.), from poisoning, or as an expression of a profound 
cachexia — adds greatly to the difficulty of determining a com- 
25 



386 CONSTITUTIONAL DISEASES. 

mon specific cause. The close relationship to scurvy, endocar- 
ditis and probably acute rheumatism suggests the possibility 
of an infection. In some cases the essential feature appears to 
be a weakness of the coats of the blood vessels; in others, alter- 
ations of the blood seem to be the responsible cause; again, 
powerful nervous influences have undoubtedly been at work, 
and in some, auto-intoxication may be demonstrated. 

Clinical experience sanctions the recognition of at least three 
forms of purpura, i. e., purpura simplex, purpura rheumatica, 
and purpura haemorrhagica (morbus maculosus Werlhofii). To 
these Osier adds "symptomatic purpura," under which he 
groups purpura accompanying certain infections (pyaemia, sep- 
ticaemia, endocarditis, typhus, measles, scarlet fever, small- 
pox), those of toxic origin (snake-bites, jaundice, drug-erup- 
tions, as from ergot, belladonna, quinine, mercury, iodides), 
those of cachexia (scurvy, Bright's disease, Hodgkin's disease, 
debility of old age), those of neurotic origin (as the stigmata 
or "bleeding points" of hysteria and the haemorrhagic effu- 
sions seen in certain cases of acute or transverse myelitis, in se- 
vere neuralgia, or in some cases of locomotor ataxia), and 
those of mechanical origin (as in epilepsy and whooping cough). 

Purpura simplex is the mildest form, most frequently met 
among children. The haemorrhagic effusions are most conspic- 
uous on the legs, but ecchymotic spots also appear on the trunk 
and arms. The haemorrhage is purely cutaneous, and, save oc- 
casional tendency to loss of appetite and slight diarrhoea, no 
constitutional disturbances are noted. Recovery takes place 
within a week or a fortnight. The so-called purpura urticans 
is a subdivision of this form, characterized by elevations in the 
skin, resembling wheals, into which haemorrhagic effusion has 
taken place. 

Purpura rheumatica (peliosis rheumatica, Schoenlein's dis- 
ease) is characterized by the occurrence of multiple arthritis, 
accompanied with dragging pains in connection with the haem- 
orrhage. Purpura urticans is very common in connection 
with this form; sometimes the eruption is pemphigoid. 
The purpuric spots are most abundant on the legs and about 
the affected joints, and oedema is usually present. It is often 
seen in men of from twenty to thirty years of age. Constitu- 
tional disturbances are: sore throat, moderate fever, with a 



PURPURA. 387 

temperature ranging as high as 103°, pain in the joints which 
is most pronounced as the rash appears, scanty and albumi- 
nous urine. Relapses are not uncommon, often occurring for a 
number of years at the same time. The prognosis is good, but 
sloughing of the uvula may take place. 

In some cases, especially among children, there is a tendency 
to the development of pronounced gastro-intestinal and renal 
symptoms. Attacks of distressing colic, with vomiting and 
diarrhoea, set in, usually at night, and sometimes recur with 
striking regularity. In such cases there may be haemorrhage 
from the bowels. The urine becomes albuminous, contains tube 
casts, and there may be haematuria. The course of these cases 
often is very tedious, and the termination fatal from severe 
gastro-intestinal disturbances or from nephritis. 

Purpura hemorrhagica has not only extensive ecchymoses, 
but also haemorrhages from the mucous surfaces into the inter- 
nal organs and the serous membranes. It occurs ' of tenest in 
delicate young persons, especially girls, but is also seen in chil- 
dren and in adults of full habit. There usually is a prodromal 
stage, consisting of weakness and prostration, lasting several 
days, followed by the appearance of purpuric spots on the skin, 
rapidly growing worse, with bleeding from the mucous sur- 
faces (epistaxis, haemoptysis, haematemesis, haematuria). Some- 
times there is an elevation of the temperature up to 101° or 
103°; there may be no fever. Arthritic symptoms are usually 
present, and complications may occur, as haemorrhagic nephri- 
tis or endocarditis. Here, also, especially in children, gastro- 
intestinal disturbances may be seen. 

Favorable cases terminate within a fortnight. Some cases, 
especially in children, with severe cutaneous haemorrhages, rap- 
idly drift into a hopeless condition, and death has been known to 
occur within twenty -four hours even without previous bleeding 
from mucous membranes {purpura fulminans) . 

Treatment.— In symptomatic purpura the treatment must be 
directed to the primary cause. The simple form requires little, 
if any, treatment. In the severe forms every means must be 
employed which will support the patient, including good food, 
fresh air, tonics, and rest in bed. The bleeding must be 
promptly controlled. For the latter purpose ergot, perchlor- 
ide of iron, aromatic sulphuric acid, acetate of lead, and other 



388 CONSTITUTIONAL DISEASES. 

astringents, may prove useful. Hot or cold water, tampons, 
spray of perchloride of iron, etc., or mechanical means, as pres- 
sure, but not ligation, must be employed. Hale recommends 
the local use of arnica and hamamelis in ten to twenty per cent, 
solution, especially when the bleeding is "oozing;" he also sug- 
gests l^drastis. Our chief reliance, however, lies in the appli- 
cation of the indicated remedy. 

Therapeutics.— Lachesis: Greatmental and physical exhaus- 
tion, with flickering before the eyes, fainting, and almost pulse- 
lessness. The feet are icy cold. Ecchymoses all over the body, 
large blotches, with red and black streaks running into the sur- 
rounding tissues; haemorrhage from the nose and bowels; jaun- 
dice.— Crotalus: Tremulous weakness; weakness at the heart 
with faintness; thready pulse; coldness and insensibility of the 
skin; oozing of dark fluid blood; blood stringy or loosely 
clotted. — Arsenic: Symptomatic purpura (sepsis, etc.). Great 
burning heat within, with external coldness. Dyspnoea; rest- 
lessness; thirst; anguish; fear of death; thready pulse. Pur- 
puric spots on neck, chest, abdomen. Haemorrhage from 
stomach and bowels, dark and offensive. External dry 
warmth feels grateful. Worse at night.— Phosphorus: Stub- 
born, persistent, dangerous bleeding from small wounds or ves- 
sels, with fainting and great thirst; water is rejected from the 
stomach about as soon as swallowed. Haemorrhage from in- 
ternal organs (haemoptysis). In fevers. Weakness of the heart. 
Albuminuria.— Secale: Haemorrhage dark, foul; symptomatic 
form (small-pox). Profound prostration, with great faintness 
and external coldness, but unwillingness to keep covered up, 
and aggravations from external warmth. — Sulphuric acid: 
Dark haemorrhage from the outlets of the body, vomiting of 
dark blood; bleeding from the oral mucous membrane. Pur- 
puric spots on forearm and legs. Exhaustion. Tremor. Said 
to be particularly useful in old persons.— Ferrum: The consti- 
tutional symptoms are comparatively light, and the danger lies 
chiefly in the predisposition to passive, long-continued bleeding. 
Moderate bleeding from nose and lungs. The skin is delicate 
and flushes easily. The blood is dark, and there is much de- 
bility.— China: Great exhaustion, with profuse cold sweating. 
Soreness all over. Both sweating and purpura worse on the 
side on which he has lain. Periodicity of the symptoms. Jaun- 



HEMOPHILIA. 389 

dice. An excellent remedy to overcome the weakness and other 
ill effects of the bleeding after recovery from the disease.— Bel- 
ladonna: Haemorrhage active, copious, from the vagina and 
rectum, bright red, and feeling hot to the parts over which it 
passes. In gushes. — Ipecacuanha: Haemorrhage copious and 
bright-red. Continued nausea. — Arnica: Copious red "oozing" 
from the capillaries. — Carbo vegetabilis: Copious, dark haem- 
orrhage in small stream or steady dropping. Epistaxis. Feels 
faint, wants to be fanned. — Terebinthina: Renal complica- 
tions; haematuria. — Millefolium: Active, alarming epistaxis. 
Purpura fulminans (?). — Rhus venenata: Small, painful ecchy- 
moses; bleeding gums; haematuria; paralytic weakness and 
soreness of the legs, better from moving them; restlessness, 
sleeplessness. 

Consult also for symptomatic purpura: Baptisia, Ailanthus, 
Rhus toxicodendron; for neurotic purpura: Strychnia, 
Cicuta, Hyoscyamus, Chloral; for arthritic purpura: Ledum. 



HEMOPHILIA. 

This term is used to express a peculiar tendency to haemor- 
rhage, possibly spontaneous, but probably always traumatic. 
It is congenital and hereditary, passing through many succes- 
sive generations. It shows a decided preference for males, these 
inheriting it through the mother. A man, being one of a family 
of "bleeders," who has married a woman wholly free from this 
predisposition, will not transmit the predisposition to haemo- 
philia to their children; if a man, wholly free from this predis- 
position, marries a woman who belongs to a family of 
"bleeders," some of their children, at least, will exhibit this ten- 
dency to bleeding, even though the mother herself may be per- 
ectly free from it. "The inheritance of haemophilia is often 
from the father, through the daughter, to the grandson; also 
from the mother, through the daughter, to the grandson; and 
most rarely directly from the father to the son" (Hoessli). 
There is nothing in the appearance of the subject to indicate 
the existence of this anomalous condition. It is stated that 



390 CONSTITUTIONAL DISEASES. 

large men of fair complexion, delicate skin and full, distended 
cutaneous veins are more frequently the victims. 

It is presumed the cause of haemophilia lies in an abnormal 
delicacy' of the walls of the blood vessels, e asily leading to a 
rupture, or in deficient coagulability of the blood. 

The clinical history may be summed up in the tendency to per- 
sistent and usually alarming haemorrhage without adequate 
cause. The slightest injury, as the prick of a pin, or a trifling 
operation, as vaccination or the extraction of a tooth, will 
cause bleeding which by its persistency may defy all the com- 
monly effective means of arresting haemorrhage. It is probable 
that many fatal cases of umbilical haemorrhage in the newborn, 
or of uncontrollable epistaxis from such slight causes as blow- 
ing the nose, or of dangerous bleeding of the gums from the 
use of the tooth-brush, are manifestations of this strange con- 
dition. Undoubtedly, fatal haemorrhage of women after child- 
birth frequently arises from this cause. The rarity of haemor- 
rhage into the substance of the viscera without previous trau- 
matism constitutes an important part of the differentiation 
between haemophilia and the acquired haemorrhagic diathesis. 

The prognosis depends upon the degree of difficulty of con- 
trolling the haemorrhage. While "bleeders" recover with sur- 
prising readiness from the loss of large amounts of blood, it is 
evident that eventually profound anaemia must result and 
shorten life. If childhood has been safely passed, each addi- 
tional year of life lessens the danger of violent attacks, and old 
age in some cases is safely reached. At any time, however, a 
trifling injury may prove serious, either because of inability to 
control the bleeding or on account of resulting anaemia. 

The treatment is largely prophylactic. The danger of mar- 
riage to a woman with a suspicious history, as to haemophilia, 
is evident. Children who may be suspected of possessing this 
predisposition should be made the subjects of every possible 
care, both as to hygiene and medication, to improve their gen- 
eral condition, and should be religiously guarded against even 
trifling injuries which otherwise would receive no attention. 
In case of bleeding, recourse must be had to surgical methods. 






PART III. 

DISEASES OF THE NERVOUS 
SYSTEM. 



PART III. 

Diseases of the Nervous System. 

MENTAL DISEASES. 

It may be said that a man is sane when his intellectual facul- 
ties and emotions are properly developed and act harmoniously, 
when his will-force is normal, and when he possesses the power 
to receive, weigh, and accurately register impressions and evi- 
dence. Whenever the emotions are unduly stimulated or de- 
pressed or the intellectual faculties are perverted, thus giving 
to some emotion or faculty, or to some group of them, undue 
prominence at the expense of others equally necessary to a 
proper way of living, mental health is impaired to that extent. 
Such impairments are common and may be harmless. The ec- 
centricities noted in our neighbors, and by them in ourselves; 
the offensive or, often, harmless activity of a "crank;" the self- 
asserting zeal of the religious fanatic who neglects the most 
pressing duties of home life for the sake of obeying a fancied 
divine call to preach on the public streets, are the beginning of 
a borderland which extends well towards the doors of the In- 
sane Asylum. The population of this borderland is the most 
varied of any upon earth and embraces many whom the world 
has cause to honor and bless. It is graded from the harmless 
enthusiast to the inspired prophet and leader, or from the 
petty thief to the homicide. 

An exact dividing line between sanity and insanity cannot be 
established. One state glides into the other so imperceptibly 
that the attention of friends and of the public is not drawn to 
the subject until he has unexpectedly given evidence of having 
become a source of danger to himself and others or stands ac- 
cused of some crime. He cannot be considered insane unless it 



394 DISEASES OF THE NERVOUS SYSTEM. 

is proved that he has no longer the power to receive, weigh and 
register adequate evidence; the loss of this power constitutes 
insanity. 

Insanity is not a clear-cut disease, characterized by certain 
anatomical changes, but a symptomatic condition which may 
be associated with, and presumably results from, certain or- 
ganic changes in the brain, or which may occur without the 
slightest evidence of cerebral lesion. The manner of its onset 
varies; its development may cover many years and take place 
so insidiously that it is impossible to fix upon the time when the 
first deviation from a normal state occurred; or it may come 
on suddenly, without warning, and with every evidence of ab- 
solute hopelessness at the very beginning. Certain abnormal 
conditions, however, commonly exist and indicate mental un- 
soundness. 

Disturbances of the emotional life are among these, and they 
occasionally are pronounced and then easih- recognized. Some 
one of the emotions, as fear, may overshadow and control all 
the others, or there may prevail a state of general emotional 
irritabilit}' which brings into prominence now one, then 
another, occasionall}' resulting in a picture of emotional ac- 
tivity which is kaleidoscopic. The former, however, is by far 
the more common and characteristic of the insane state. In 
certain affections there is a continuous lessening of emotional 
life, associated with failing intellectual power. In the sane sub- 
ject, the emotions are under the control of the will, and daily 
observation shows the strength of this inhibitory power of the 
will. A person easily angered may b3^ the habitual exercise of 
his will-power overcome what may justly be considered a devi- 
ation from a perfectly normal state; such will-power not being 
exercised, the periods of anger will occur oftener, upon con- 
stantly slighter provocation, and with more disastrous results, 
until it becomes difficult to determine whether we deal with a 
fit of ugly temper or with a condition which has in it a very 
important element of mental unsoundness. A clear realization 
of the practical value of a well-taught will-power and its salu- 
tary influence throughout life is at the basis of a good education. 
Children should never be allowed, under the plea of "nervous- 
ness," and similar nonsense, to give way to fits of emotional 
excitement upon slight provocation. This applies most em- 



MENTAL DISEASES. 395 

phatically to children of a neurotic tendency. Whatever 
weakens the will, also weakens the inhibitory influence pro- 
vided for the control of the emotions. Certain diseases, as 
hysteria, are found in persons who lack in will-power. Some 
conditions weaken the will, and among these the most promi- 
nent are chronic alcoholism, great physical exhaustion, such as 
result from acute and severe illness, great deprivation or hard- 
ship (imprisonment, starvation, exposure to the elements, etc.), 
and the decay which accompanies old age. 

The in tellectual faculties are nearly always impaired. The 
first indication of failure is loss of memory, then inability to 
fix the attention upon one subject, followed by incoherency in 
action and speech. The latter may be due to cerebral hypere- 
mia, in which case there is increased rapidity of intellectual pro- 
cesses which outstrips the ability to give expression to the 
quickly moving thoughts. Exceptionally there is remarkable 
vigor of the intellectual faculties, making it possible to per- 
form intellectual tasks of the greatest difficulty without expe- 
riencing fatigue. Such state is usually characterized by cerebral 
hyperemia and insomnia, often results from mental overwork 
done under heavy stimulation, and may be the forerunner of 
acute encephalitis or paretic dementia. 

More immediately connected with mental unsoundness are 
the phenomena described as illusions, hallucinations, and delu- 
sions. An illusion is a false or distorted sensation, clothing 
some external object in characters which it does not possess; a 
hallucination is the perception by any of the senses of an object 
which has no existence. If a person in a room to another ap- 
pears in the form of a tree growing out of the ground or as an 
angel from heaven, arrayed in heavenly garments, the person 
experiencing this false impression is laboring under an illusion; 
the perception of some object in the room for which there is no 
material basis whatever, as in a room wholly bare and unoccu- 
pied, would be a hallucination. Usually one sense only is thus 
involved. Voices are heard, visions seen, touches felt, odors 
perceived and tastes experienced which do not exist save in the 
morbid sense organs of the subject himself; hence they are 
wholly subjective. If suggested by an existing external object, 
and perverted by the sense organs, they are objective. 

Although illusions and hallucinations are common among the 



396 DISEASES OF THE NERVOUS SYSTEM. 

insane, and do essentially belong to mental unsoundness, they 
do not necessarily indicate insanity. A man, able to be about 
his business, may hear voices about him, or the voice always of 
the same person, or may see human forms standing near him; 
these will annoy him and possibly render him apprehensive; 
but his reason may tell him that these voices and forms have 
no existence in fact, and he will go on in the pursuit of his voca- 
tion; or a friend, possibly his physician, whom he has taken 
into his confidence will find him a willing listener, ready to be 
convinced that the voices and forms are in reality hallucina- 
tions. Such a person is not insane. Insanity, however, does 
exist when the subject is no longer able to receive and duly con- 
sider the external evidence presented to him; when it is no 
longer possible to convince him of the falsity of his perception; 
when his reason ceases to be an active factor in forming a con- 
clusion. The subject of the hallucination now considers it tan- 
gible, real, and believes in it; he labors under an insane delusion, 
and is to all intents and purposes insane. 

The character of the delusion and the emotional deviations 
are closely related, but it is not easy to affirm which is the de- 
termining factor. A delusion of a terror-inspiring character 
will naturally excite emotions of terror and abject fear, just as 
the primarily excited emotion of terror will undoubtedly affect 
and probably determine the general character of the delusion 
which is entertained. 

The forms of delusion oftenest seen are: The expansive form, 
found in the delirium of grandeur, the patient investing his per- 
sonality with exalted characteristics, as exquisite beauty, gi- 
gantic strength, divine goodness or wisdom, untold wealth, 
etc. The hypochondriac form, nearly always associated with 
a depressed state of the emotions. One of the commonest forms 
is the utter despondency of sexual hypochondriacs who cling 
to the belief that they have utterly and forever ruined their 
health by sexual vice. The delusions of persecution, usually 
connected with hallucinations, particularly of hearing; they are 
dangerous and not infrequently result in homicide, the subject 
endeavoring to relieve himself of a fancied persecutor or to 
avenge himself for some wrong which, he thinks, has been done 
him. 

An imperative conception is some false idea, some notion 



MENTAL DISEASES. 397 

which in some inexplainable way takes possession of a person 
and is liable to influence his actions unless overruled by his rea- 
son or will-power. This impression or notion may urge the 
subject to commit* a certain act; the impulse itself is called a 
morbid impulse, and the act, if committed, is known as an im- 
perative act. These may all be restrained by the assertion of 
reason, and it is not infrequent to meet in practice men or 
women whose lives have become a perfect purgatory as the re- 
sult of some morbid impulse which haunts them at all times, 
whose nature they recognize, and whose power they heroically 
resist. The impulse itself may, or may not, be based upon a de- 
lusion. 

The frequency with which these impulses occur, and their va- 
riety, have led to the coining of names which express their 
character; thus, kleptomania, the morbid impulse to steal; 
pjromania, to set fire to buildings; arithromania, to spend all 
one's time in making calculations; nymphomania, morbid and 
unappeasable desire in women for excessive sexual intercourse; 
erotomania, a sexual insanity in men, which consists wholly of 
a Platonic attachment, etc. 

Changes in character axe. marked, and must be determined by 
comparing the patient with his former, better self. A rapid 
change from a high standard of moral living to indulgence in 
excesses of any kind and in riotous living; from a generous 
husband and father to a domestic tyrant and brute; from a 
thrifty, careful business man to a gambler and spendthrift; 
from a man of truthfulness and clean speech into a habitual liar 
and blackguard— all these are the outcome of an affliction 
which is worse than death and which may come to any. 

The classification of forms of insanity is so difficult a task that 
as yet none has been made which is in every sense satisfactory. 
The following, closely adhering to that of Krafft-Ebing, is 
adopted by H. C. Wood. (Pepper: "American Text-Book"): 

Complicating or Organic Insanities. — Here insanity results 
from a well-defined organic disease of the brain and is often of 
secondary importance clinically. In acute periencephalitis 
(Bell's disease; acute delirium) and in chronic periencephalitis 
(General Paralysis of the Insane) the mental symptoms com- 
pletely overshadow the brain lesion. 

Constitutional Insanities. — These are due to some constitu- 



398 DISEASES OF THE NERVOUS SYSTEM. 

tional diathesis or disease, inherited or acquired, as gout, 
syphilis, epilepsy, hysteria, or to constitutional poisoning, 
chief! } 7 chronic alcoholism. 

Pure insanities, in which neither organic brain-lesion nor 
constitutional diathesis or disease, nor chronic poisoning, can 
be found to account for the mental disorder. These are divided 
into (a) functional insanities (melancholia, mania, confusional 
insanity, terminal dementia) which occur in those who seem to 
possess no particular tendency to mental disease, are often 
brought on by causes which operate for a limited time, and 
from which recovery is frequently had; (b) constitutional in- 
sanities (constitutional affective insanity, moral insanity, par- 
anoia, periodic insanity), which depend upon a neuropathic ten- 
dency; these forms usually develop gradually and become more 
pronounced with increasing years; permanent recovery here is 



ORGANIC INSANITIES. 

ACUTE PERIENCEPHALITIS. 

Acute periencephalitis, acute delirium, Luther Bell's disease, 
phrenitis mania gravis, or typhomania, is an acute disease of 
the brain, involving the cerebral cortex and meninges, charac- 
terized by violent mania, fever, coma and collapse. It occurs 
in adult life, regardless of sex, and in persons who have endured 
much anxiety, often great privations, usually associated with 
ambitious aims never realized; in all such cases, connected with 
much wear and tear of the nervous system, some sudden bitter 
disappointment or great sorrow may constitute an immediate 
exciting cause. It occasionally occurs in connection with acute 
fevers (thermic fever) or from some injury (blow) to the head. 
It presents no distinctive anatomical changes. After death in- 
tense hyperaemia of the cerebral cortex and meninges is found 
to exist, followed by oedematous exudations with great num- 
bers of leucocytes in the lymph sheaths and perigangliar 
spaces. There may also be engorgement of the bases of the 
lungs and, occasionally, deglutition pneumonia. 

Symptoms. — The onset of the disease may be sudden or pre- 
ceded by restlessness, slight delirium at night, occasionally brief 
attacks of unconsciousness, not unlike petit mal, especially in 



MENTAL DISEASES. 399 

the morning, and rarely an epileptiform seizure. Suddenly de- 
lirium sets in, which from the very start assumes the form of 
an actual frenzy. The patient yells, screams, fights, attempts 
to get away from his attendants, gesticulates wildly, and con- 
tinues in an ecstacy of maniacal excitement which appears be- 
yond the endurance of the strongest man. He usually has hal- 
lucinations and vaguely formed delusions about which he talks 
wildly and incoherently. This delirious state at first may be 
interrupted by brief periods of rest, but these grow shorter, and 
soon cease. During this time the tongue is dry, the pulse 
rapid, but comparatively soft and compressible. The temper- 
ature often ranges from 102° to 104°, and possibly higher. 
Wood states that it rises and falls many degrees many times 
during the twenty-four hours, and that maniacal outbursts 
produce an immediate rise of the temperature. Insomnia is al- 
most absolute, and it may require heavy doses of hypnotics to 
give the patient any rest. Food is usually refused and admin- 
istered under great difficulties. The eyes present nothing char- 
acteristic; the pupils may be contracted, dilated, or normal. 
The skin at first is hard and dry; later it peels off, and before 
the termination of the case may be ulcerated or gangrenous in 
spots, and covered with abrasions and wounds which the pa- 
tient has inflicted upon himself. Anaesthesia is usually present. 
The violence of the delirium subsides in the course of hours or 
days, leaving the patient in a state of utter exhaustion and in a 
comatose condition from which at first he may be roused. The 
coma soon becomes profound, the temperature sinks to subnor- 
mal, the pulse grows weaker, the skin cool, and death takes 
place from collapse. 

The diagnosis is rarely difficult. 

Typhoid fever bears considerable resemblance to the late 
stage of acute delirium, but in typhoid fever the characteristic 
eruption, the splenic enlargement, and the history of the case 
establish the identity of the disease. Pneumonia may have 
violent delirium and is easily overlooked. But cerebral pneumo- 
nia almost always occurs in young children or in old people 
whose vitality has been exhausted by excesses, while acute de- 
lirium is a disease of middle life; the presence of the physical 
signs of pneumonia must be looked for. Acute meningitis has 
general hyperesthesia, stiffness of the muscles of the back and 



400 DISEASES OF THE NERVOUS SYSTEM. 

extremities, and severe headache. Uraemic convulsions may 
have violent acute mania, followed by coma; but the fever of 
acute delirium is absent, and examination of the urine will de- 
termine the diagnosis. 

The course of acute periencephalitis is rapid. Severe cases 
usually terminate within a week; others in two or three weeks. 

The prognosis is unfavorable. From sixty to seventy per 
cent, of all the cases die; the others rarery make a complete re- 
covery, some mental derangement usually remaining. 

Treatment. — The routine treatment consists of general and 
local bleeding, the efficacy of which is universally admitted, of 
free purging, and of the use of cold applications to the head, of 
the cold pack and the cold bath. Sleep must be induced by 
hypodermic injections of morphia or hyoscin or chloral hydrate 
by the mouth. Good results have of late been claimed for hy- 
podermic injections, every eight hours, of one gramme of ergo- 
tin or of the filtered solution of the officinal extract of ergot in 
freshly boiled water. Cardiac and alcoholic stimulants are in- 
dicated in the late stages. Much attention should be paid to 
feeding the patient, particularly milk and eggs. 

Aconite, Belladonna, Hyoscyamus, Stramonium and other 
remedies capable of controlling the existing cerebral hyperemia 
and inflammation, and covering the type of delirium here found, 
are to be exhibited; they usually render bleeding unnecessary. 
Indications will be found under the general heading "Therapeu- 
tics of Insanity." 

CHRONIC PERIENCEPHALITIS. 

Synonyms.— Paralysis of the insane; paretic dementia; peri- 
encephalo-meningitis; general progressive paralysis; general 
paresis; chronic diffuse meningo-encephalitis. 

General paralysis of the insane consists of a degeneration of 
the cerebral cortex and meninges, sometimes extending to the 
medulla and cord, characterized by motory derangements ter- 
minating in paralysis and psychical changes terminating in 
mania, delusions, and dementia. 

/Etiology.— This affection occurs very much oftener in men 
than in women, the latter constituting about one-sixth of the 
entire number. It is essentially a disease of middle age, from 
the fortieth to the fiftieth year. It is said that the intense ap- 



MENTAL DISEASES. 401 

plication of Americans to business renders them liable to fall 
victims to general paralysis earlier in life than is the case in 
other countries. The most active predisposing factor is a well- 
defined neurotic tendency, intensified by habitual hard, fast liv- 
ing, with indulgence in all sorts of excesses, intense application 
to business, indulgence in alcoholic stimulants or venereal ex- 
cesses, with their frequent accompaniment, syphilis. Ambitious 
professional men, actors, and officers in the army and navy 
furnish many cases. Heredity is of slight importance. Tumors 
of the brain, sunstroke and injuries to the head may be ex- 
citing causes. 

Morbid Anatomy — The changes usually begin in the cerebral 
cortex and later extend to the medulla and spinal cord; some- 
times these all are simultaneously involved; exceptionally the 
spinal cord is affected first. Upon section there is found thicken- 
ing and opacity of the meninges, which often firmly adhere to the 
cortex; oedema of the pia mater; often internal hemorrhagic 
pachymeningitis; increase of cerebro-spinal fluid; marked 
atrophy of the cerebral convolutions, especially of the frontal 
lobes. The brain-cortex is sometimes firmer, again softer, than 
normal, and often contains minute cysts or cavities. The white 
matter of the brain is firm and shows no striking changes; the 
gray matter is softer and obscurely outlined. 

The ventricles are dilated and their lining neuroglia granular. 
Changes peculiar to arterio- sclerosis, with softening and haem- 
orrhage, occur in the blood vessels. Bevan Lewis sums up the 
histological changes as follows: A stage of inflammatory 
change in the tunica adventitia of the arteries with excessive 
nuclear proliferation, profound changes in the vascular chan- 
nels, and trophic changes in the surrounding tissues. A stage 
of extraordinary development of the lymph-connective system 
of the brain, with a parallel degeneration and disappearance of 
nerve elements and the axis cylinders of which they are de- 
nuded. A stage of general fibrillation with shrinking and ex- 
treme atrophy of the part involved. 

Symptoms. — What may be called the prodromal stage of the 
disease consists of a condition which at first closely resembles 
the cerebral form of neurasthenia. The patient appears some- 
what unsettled, irritable and notional; he is easily excited, and 
finds it difficult to fix his attention upon work in hand or to do 
26 



402 DISEASES OF THE NERVOUS SYSTEM. 

mental labor which heretofore has been performed with ease. 
In the course of time members of the family and intimate asso- 
ciates realize that some change has come over him. Mental and 
plrysical restlessness, with insomnia, often becomes a source of 
annoyance. He has headache, dizziness, ringing in the ears. 
Krafft-Ebing points out that a characteristic feature of its 
stage is a growing lack of punctuality in meeting engagements 
and a tendencj' to get lost in familiar streets. The change of 
character and habits is progressively downward. He grows 
inattentive to business; often he develops a craving for alco- 
hol, and, heretofore a man of sobriety, now tipples constantly 
and possibly drinks heavily; he grows coarse, indifferent to the 
common courtesies of life, drifts into sexual excesses in his 
family or outside of it, and is liable at any time to commit 
flagrant offenses against the law and common decency. In 
many instances a boundless egotism crops out. Motor disturb- 
ances ma3 r have already existed, but now become pronounced; 
the speech and gait, hereafter more fully described, become char- 
acteristic; there is inequality of the pupils, often the Argyll- 
Robertson pupil. Physical exhaustion increases perceptibly; 
sometimes there is now paresis of the extremities. Epilepti- 
form seizures are common, and mania is a prominent feature 
of the case. Eventually both mind and body are wholly 
wrecked. There is complete dementia and general paralysis, an 
actual living death. The end comes from exhaustion or some 
intercurrent affection. 

It is possible to recognize distinct types. There may be sim- 
ply progressive failure of the mental powers, without marked 
emotional disturbances, the patient drifting into a second child- 
hood; these cases are known among the people as "softening" 
of the brain. Another class has the same progressive mental 
failure, but also delusions of grandeur, with outbursts of vio- 
lent mania. Again, hypochondriasis may be the most promi- 
nent mental symptom, rendering the patient exceedingly de- 
pressed and determining the nature of the delusions under 
which he labors. Or, less often, periods of excitement and of 
depression alternate, succeeding each other rapidly, and consti- 
tuting a periodic or circular insanity. 

The motor defects show themselves chiefly and early in disor- 
ders of co-ordination. This is first shown in the hand, particu- 
larly in persons who write as a matter of business, in profes- 



MENTAL DISEASES. 403 

sional engravers, and in mechanics whose work is delicate and 
requires perfect muscular control; there is not necessarily loss 
of gross muscular power. Speech becomes disturbed on ac- 
count of faulty action of the lips and tongue; it is thick, stut- 
tering, and entire syllables may be "swallowed." The mental 
faculties having become involved, he thinks slowly and formu- 
lates thoughts into words slowly; hence, speech is also slow 
and hesitating, sometimes uttered in a "sing-song" fashion. 
The gait is uncertain, especially when he attempts to turn 
quickly; often it is ataxic. As the disease progresses he can 
scarcely go up or down stairs, walks with feet wide-spread, 
tumbles down easily, and in walking assumes a position of 
body which shows that he is constantly afraid of falling. 
Finally, he can no longer stand or walk, and is forced to spend 
the remainder of life in a recumbent position. The knee-jerk is 
usually exaggerated. Vesical and rectal symptoms develop as 
paralysis becomes profound. Epilepsy may occur very early in 
the course of the disease, and its full significance is then rarely 
appreciated. The convulsions may be general or of the Jack- 
sonian type, with or without loss of consciousness. They are 
frequently preceded by a vertiginous aura. They are liable to 
increase in frequency as the disease progresses, and are followed 
by incomplete paralysis or great muscular weakness and 
tremors. When the seizures are general and severe, conscious- 
ness is usually lost; exceptionally they prove fatal. Apoplecti- 
form attacks are not so frequent. They may come on gradually 
and disappear in the same manner, leaving more or less motor 
disturbances and lack of muscular power; sometimes they are 
severe and cause hemiplegia; rarely they prove fatal. Sensibility 
is not greatly disturbed, though lessened in the advanced stage. 
The patient may have tactile sensation, and yet complete anal- 
gesia. Thus H. C. Wood relates the case of a woman who took 
a bath so hot that she was actually scalded to death. Violent 
lancinating pains cause much suffering if tabes forms a feature 
of the case. The temperature is nearly always elevated in the 
evening. Perhaps its most striking peculiarity is the sudden 
and great rise from slight causes. Epileptiform seizures are 
often, but not always, preceded and followed by an elevation 
of temperature for several hours. 
The symptoms arising from disease of the spinal cord may 



404 DISEASES OF THE NERVOUS SYSTEM. 

precede or follow the stage of mental disturbances; they follow 
in 30 per cent, of the cases. 

Diagnosis. — The recognition of dementia paralytica in the 
early stage is exceedingly difficult. It depends very largely 
upon a careful comparison of the subject's present mental con- 
dition and conduct, in every direction, with his previous mental 
state and former conduct; if no explanation can be found for an 
existing and undesirable change of character and life, and espe- 
cially if cerebral vaso-motor disturbances are apparent, the ap- 
proach of paretic dementia may be suspected. This suspicion 
will become an almost certainty in the presence of characteris- 
tic pupillary changes and evidence of muscular incoordination. 

While alcoholic insanity, acute mania, or monomania with 
delusions of grandeur in some respects resemble general paresis, 
the similarity is too superficial to create embarrassment. 

Cerebral syphilis, however, presents many symptoms which 
suggest general paresis; but in syphilis epilepsy is much oftener 
local than general; symptoms of paralysis occur earlier, expan- 
sive delirium is rare, embarrassment of speech from muscular 
incoordination is absent, and antisyphilitic treatment usually 
affords relief. 

Prognosis. — Recovery is so rare that hopes of it dare not be 
entertained. The duration of the disease is usually from three 
to four years, but life may be spun out for ten or even fifteen 
years. There are occasionally periods of remission, -with re- 
markable improvement of the patient, which afford ground for 
delusive hopes of actual gain. 

Treatment. — The general treatment consist of relief of sleep- 
lessness by appropriate measures, careful nursing, perfectly 
quiet life, with an abundance of plain, wholesome, non-stimu- 
lating food, warm clothing, massage, bathing and carefully 
regulated exercise in the open air. All these can best be secuedr 
in an asylum. In the late stage special precautions must be 
taken to enforce perfect cleanliness, especially in protecting the 
patient against being soiled by discharges from the bladder and 
bowels, in order to prevent decubitus. 

If syphilis is connected with the case, the iodide of potassium 
must be given for a long time, from ten to fifteen, or more, 
grains daily. 

The remedies which are useful in the treatment of insanity 



MENTAL DISEASES. 405 

and of epilepsy must be consulted. Belladonna, Aurum, 
Platina, Hyoscyamin, Stramonium, Picric acid, Silica, 
Arsenic, Nux vomica, Strychn. arsen., and many others, will 
at various times be suggested by symptomatic indications. 

CONSTITUTIONAL INSANITIES. 

Of the forms of insanity which occur in connection with con- 
stitutional diseases and subacute or chronic systemic poisoning, 
the most important are the gouty, the epileptic, the hysterical, 
and the toxaemic. 

Gouty Insanity. — The close relation between gout and the 
nervous system has long been recognized. Cullen considered 
gout primarily an affection of the nervous system, in view of 
the common occurrence of marked neurotic symptoms, ranging 
from violent headache, neuralgia, sciatica and paresthesia to 
serious cerebral disease, particularly basilar meningitis and 
apoplexy. Seizures of gout are commonly associated with, 
and may be preceded by, great mental depression; excessive irri- 
tability, almost uncontrollable and sometimes amounting to a 
furious state, are common. Hallucinations, delusions and loss 
of mental power are known to have followed these manifesta- 
tions, and Berthier, in a study of this subject, shows that de- 
mentia, melancholy with stupor, and mania have resulted from 
the constitutional affection. It is probable that the existence 
of a hereditary predisposition to insanity must be recognized 
in such cases. 

Epileptic Insanity is characterized by violent delirium which 
may last only a short time, but often continues for days, with 
ideas of persecution, sometimes with erotomania, and inces- 
sant and boisterous talking; the hallucinations partake of the 
type of the emotional disturbances. A furious mania is not in- 
frequent, with suicidal or homicidal tendency. The paroxysms 
may be of frequent occurrence and resemble one another. The 
tendency is to mental degeneration and dementia. True in- 
sanity may occur, usually melancholia, with ideas of persecu- 
tion. The disposition in such cases frequently is selfish, re- 
vengeful, brutal. I had for years under my observation an 
epileptic boy, about eighteen years of age. His chief amuse- 
ment consisted of catching animals, chiefly dogs and cats, 



406 DISEASES OF THE NERVOUS SYSTEM. 

whom he would torture and finally kill by cutting their throat 
with a dull jack-knife, often himself receiving bad hurts in their 
desperate attempts to escape or defend themselves. He was 
confined after making an assault upon a younger brother, and 
soon died, wholly demented. 

The term Hysterical Insanity applies to that mental irrespon- 
sibility which is the outgrowth of the reckless indulgence of 
"self and of the intense emotional excitability which charac- 
terizes the hysterical state. In fact, it is an exaggeration of 
the mental and emotional manifestations of hysteria, possess- 
ing to the full extent its love of self, its tendency to all kinds of 
deception, intangible notions and delusions, perverted imagina- 
tion and liability to all kinds of fictitious diseases, terminat- 
ing in actual, often intense, suffering, and demanding restraint 
for the protection of the patient and these about her. Such 
cases are not infrequent and by their recurrence may result in 
permanent mental derangement. 

The Toxaemic Insanities find their type in subacute and 
chronic poisoning with alcohol, which is considered under the 
heading "Alcoholism." 

PURE INSANITIES. 

MELANCHOLIA. 

Melancholia, -as it presents itself to the general practitioner, 
is in its milder form simply an exaggeration of those periods of 
mental depression which are not incompatible with health and 
to which all are more or less subject. Persons suffering from 
chronic haemorrhoidal or abdominal disease are particularly 
liable to such attacks. If such periods of mental depression are 
very pronounced and persist for a long time, there is sleep- 
lessness, not amounting to absolute inability to sleep, but con- 
sisting of wakeful, broken nights, frequently with anxious and 
distressing dreams, loss of appetite, impaired digestion, and a 
state of nervous instability which suggests neurasthenia. In 
such cases everything partakes to the patient of a sombre col- 
oring; poverty stares him in the face; ruin of reputation is 
unavoidable; he feels that he is predestined to make a miserable 
failure of life; he has no friends, no future, no comfort of any 
kind. Brooding and mental isolation are natural; his atten- 



MENTAL DISEASES. 407 

tion is fixed upon himself as the most wretched of human 
beings, and cannot be diverted. Occasionally there may be 
some real disappointment, sorrow, or loss; but it is invariably 
true that its seriousness is tremendously exaggerated or that it 
is kept fresh in the mind long after it should have ceased to ex- 
cite regret. The patient usually is worse in the morning; but 
throughout the day he is lost in apathy, sits in his chair wholly 
absorbed in himself and in his moody thoughts, entirely bey ond 
interest or concern in what is going on about him. His rea- 
soning powers at this stage are intact; if roused, he talks intel- 
ligently, but soon sinks back into the former apathy. In other 
cases, this same condition of complete absorption in depressing 
contemplations having been reached, the patient is demonstra- 
tive, talks loudly about his woes, moans and laments, wrings 
his hands, tears his hair, moves about rapidly and aimlessly, 
and is altogether unstrung. Delusions, usually unsystematized, 
prevail after a time; they are more frequently delusions of hear- 
ing, related to the peculiar form which his mental depression 
assumes, but they are invariably unpleasant and distressing; 
voices never carry to him glad news, but always bring words 
of censure or threats; the spirits that visit him never come as 
angels of light, but as fiends from hell; the odors he smells are 
never pleasing, always disgusting. 

In the severer forms the general nervous systems now gives 
signs of suffering. Sensory disturbances are common, as 
irregular hyperesthesia, anaesthesia, or paraesthesia; there is 
often persistent neuralgia and constant and severe headache. 
One of the most painful symptoms is intense precordial 
anguish, a feeling of aching in the heart as though it would 
burst, often in paroxysms associated with great bodily rest- 
lessness, gradually rising to a condition of actual frenzy, ac- 
companied with rapid and superficial breathing, excited action 
of the heart, small thready pulse, cold and pale skin. During 
this furious delirium (raptus melancholicus) the patient is en- 
tirely beyond control; he is violent in the extreme, but his de- 
structiveness is directed towards himself. He tears his hair, 
destroys his clothes, mutilates himself (often genitalia), but 
uses no violence toward others, save as they endeavor to 
forcibly interfere with his actions. These paroxysms pass off 
in profuse sweating. Furious delirium is particularly liable to 



408 DISEASES OF THE NERVOUS SYSTEM. 

occur in cases which have developed rapidly. General health 
has become lowered. Even from the first the tongue has been 
coated, the breath foul, and all appetite lost; now aversion to 
food is marked; the profound melancholic will not only refuse 
to take nourishment, but may desperately resist all attempts 
to force it upon him. Consequently the patient becomes ema- 
ciated and weak. The urine is scanty and rich in urates, phos- 
phates and oxalates. The temperature is habitually subnor- 
mal, -with harsh, clammy skin and cold legs and fest. 

Even mild cases are marked by loss of sexual desire and 
power, which are recovered when improvement takes place; in 
women the approach of menstruation causes a noticeable ag- 
gravation of the mental depression, not infrequently associated 
with great hysterical excitement. In the late stages sexual 
power is lost. 

The special forms usually recognized are: Melancholy with- 
out delirium, which by Krafft-Ebing is again subdivided into 
(a) melancholy without intellectual insanity, but associated 
with hysteria and neurasthenia; (b) melancholy with precor- 
dial anguish; (c) melancholy with hallucinations and delusions; 
(d) melancholy of a religious type; (e) hypochondriac melan- 
choly, the delusions being associated wholly with himself 
(thinks he is rotten throughout with syphilis) and usually 
tinctured with notions concerning his sexual system. 

Melancholia attonita, in which the patient is in a condition 
of stupor, leaving the impression of a demented state, save that 
to the closely observant the face betrays the play of emotions 
and the anguish produced by them. Sensory disturbances are 
common here; there is great depression of functions and nutri- 
tion; mild muscular contractions and muscular rigidity are 
common, and a cataleptic state sometimes prevails. 

Melancholia agitata is characterized by fear and terror, 
with the violent frenzy which has been described. 

The Katatonia of Kahlbaum has less profound melancholy; 
catalepsy is comparatively frequent; and there are fixed delusions 
of an expansive type, such as the belief that he is a great politi- 
cian, actor or preacher. There is a tendency to constant repe- 
tition of words and phrases (verbigeration) when talking, and 
motor-tension. Alternating cycles of atony, excitement, confu- 
sion and depression. Tendency to profound mental weakness, 
even dementia. 



MENTAL DISEASES. 409 

Melancholia is usually associated with waning physical 
power, regardless of age; such a condition, however, is oftener 
found in the more advanced period of life than during youth. 
In feeble women the physical exhaustion following confine- 
ment and the drain made upon them by lactation predisposes 
to the affection. The course varies greatly; many mild cases 
recover without any treatmnent, while others defy the most in- 
telligent measures taken. 

The prognosis is nevertheless good, for about 60 per cent, of 
all cases terminate favorably. It is, however, notable that re- 
covery is always slow. A small per cent, of all the cases end 
in dementia. Death usually is due to some complication, as 
tuberculosis. 

Treatment. — In all cases moral treatment is of supreme im- 
portance. It is practically worse than useless to argue with a 
confirmed melancholic; his attention must by some means be 
drawn from himself. To this end he should be taken from 
home. In view of the fact that even in the milder forms of 
melancholia the patient may at any time become dangerous, at 
least to himself, he cannot be sent from home alone, but must be 
in charge of a strong, intelligent and agreeable attendant, who 
is capable of assuming the really serious responsibility of such 
a case. Such an attendant is usually far more desirable than the 
wife, husband or child, whose presence is a constant reminder 
of conditions and associations which it is desirable to have 
forgotten. Experience shows that the seaside usually is to be 
avoided. Neither is any place desirable which develops a sense 
of loneliness. Opportunities for diversion and amusement are 
absolutely indispensable. If there is a lack of means to provide 
for these necessities, it is best to secure admission to some 
asylum. Wherever the patient may be, his general health de- 
mands the best care. An abundance of physical rest is highly 
beneficial, and the "rest-cure" has yielded excellent results. 
Massage, electricity, hot baths and moderate exercise in the 
open air are important. The aim of providing exercise is 
chiefly for the purpose of occupying the patient, of giving him 
something to do. Exposure to the heat of the sun must be 
carefully avoided. The diet must be abundant; experience 
shows that even patients who have been considered dyspeptics, 
and with whose diet great pains have been taken, are fre- 



410 DISEASES OF THE NERVOUS SYSTEM. 

quently much benefited by forcing upon them a large variety of 
hearty, common food, taken in generous quantities, and accom- 
panied with a moderate allowance of wine, beer, or other stim- 
ulants. In some cases an exclusive milk-diet meets all the con- 
ditions. 

Frequently a careful examination of the case reveals the ex- 
istence of some constitutional or local disease, and, if so, that 
must receive attention. Haemorrhoids and other rectal dis- 
eases are closely associated with melancholia, and their re- 
cognition and removal bears directly upon the cure of the 
mental disorder. Nervous excitement is to be subdued by 
proper management and by the exhibition of the symptomatic 
remedy. In extreme cases hyoscine (gr. T ^ ¥ to ¥ V) may have to 
be exhibited. Sleeplessness may be combated by hot baths or 
frequently changed hot packs; liberal allowance of hot milk or 
a light meal just before sleeping-time may prove very helpful. 
These measures should be honestly tried before resorting to a 
hypnotic. If they fail, chloral hydrate (grs. x to xx) are in the 
lighter cases and in the early part of the disease to be preferred 
to opium; later, opium not only yields better results in afford- 
ing sleep, but often has a desirable constitutional effect. 

At no time must the patient be left alone in the room, even 
though only for a few minutes; a seemingly harmless subject 
may take advantage of the situation and inflict upon himself 
irreparable injury. In the severe forms of the affection con- 
stant watchfulness must be exercised for sj^mptoms indicating 
the approach of a maniacal outburst. 

In the early stage the Succus Passiflora, the expressed fresh 
juice of Passiflora incarnata, given in half-teaspoonful doses 
at short intervals, may quiet the patient and give him sleep. 

MANIA. 

Mania, according to Spitzka, is a form of insanity character- 
ized by an exalted emotional state which is associated with a 
corresponding exaltation of the other mental and nervous func- 
tions; the typical condition of the maniac, according to the 
same author, is a loosening of the inhibitions, or checks, both 
those of organic and of mental life. 

The onset of mania, with rare exceptions, is not sudden. 



MENTAL DISEASES. 411 

There is, for a period of about three months, a general indispo- 
sition, with loss of appetite, foul taste in the mouth, furred 
tongue, indigestion and constipation. The head feels full and 
tense, especially over the eyes and in the occiput; there is aver- 
sion to exertion, inability to concentrate his thoughts upon 
anything, he does not sleep well, and attends to his daily duties 
only by dint of special exertion. After a time he appears to im- 
prove greatly. He eats well, sleeps well, works well, and thor- 
oughly enjoys himself. Soon it is noticed that he is rather 
emotional and in many respects seems unlike his former self. 
He appears a part of the time as though slightly intoxicated. 
His fancy is stimulated; his speech rapid, later confused. This 
confusion arises from the impossibility of transmitting the con- 
ception over the speech tracts fast enough to have them ex- 
pressed in words. He now easily glides into a declamatory 
style of speech, accompanied with impressive gesticulations 
and restless moving about; he cannot remain quiet. His 
moods change rapidly; he laughs easily one moment and is 
ready to take offense at the most trivial occurrence in almost 
the same breath; contradiction is unbearable to him. He is 
conscious of a feeling of exalted well-being and indulges himself 
readily in the gratification of every desire, often exercising a 
lavish hospitality and giving himself up to fast and riotous 
living. His moral perceptions are both blunted and overcome 
by a feeling of superiority which places him above the common 
restrictions of civilized society. He becomes openly unchaste; 
his gestures and actions are frequently those of a black-guard, 
and throughout there is a tendency to angry excitement. Illu- 
sions and hallucinations now occur; they also are usually of a 
gay, expansive character, and more frequently hallucinations 
of hearing; but all the senses may be involved. It is to be em- 
phasized that no depressing, but always expansive, delusions 
are here built up, even upon disagreeable hallucinations. Any 
severe emotional excitement of a disturbing angry character 
may now bring on violent motor delirium. The patient raves, 
yells and screams; rushes wildly about the room, smashing 
furniture, throwing chairs and dishes through the windows 
into the street, tearing off his clothing, sometimes, but rarely, 
attacking his attendants. Frequently there is much sexual ex- 
citement, i. e., satyriasis and nymphomania, and both men and 



412 DISEASES OF THE NERVOUS SYSTEM. 

women will endeavor to expose themselves nude in some public 
place, as an open window. Often the hallucinations appear to 
change constantly and in rapid succession. The sensations are 
blunted, so he is insensible to a common injury. His strength 
and plrysical endurance are wonderful; for day and night, with 
scarcely a moment's rest or sleep, he dashes about, raves, 
curses, swears, blasphemes, without an indication of weari- 
ness. 

A disgusting filthiness is peculiar to this condition, the pa- 
tient urinating and defecating anywhere and without concern 
for the presence of others, bedaubing the walls and himself 
with the excrements, and sometimes even eating them. 

Throughout, the appetite is usually excellent and digestion 
perfect, but there is constant loss of weight, undoubtedly on 
account of the long-sustained powerful exertion. 

Often periods of furious mania alternate with periods of 
comparative calm. 

Usually convalescence takes place slowly, the first indication 
of it being the occurrence of a brief period of lucidity, which is 
followed, possibly within a short time, by a recurrence of 
maniacal excitement or by a reactionary depression, but these 
periods of lucidity become more frequent, last longer, and 
finally merge into each other. 

Recovery may take place in a few days or not for a year; 
commonly the duration of the disease is from three to six 
months. The prognosis is favorable; from 60 to 80 per cent, 
of all the cases get well. Usually, a patient who has perfectly 
recovered from one attack of mania is not liable to have a re- 
currence of the disease. Acute mania may become chronic or 
a state of partial dementia may develop; death occurs from ex- 
haustion. 

Mild cases present to a varying degree the emotional and 
mental conditions described, with insomnia, hallucinations 
and immodesty, but escape the furious delirium. 

Chronic mania is the outgrowth of acute mania or of a 
slowly developing mania which lacks the violence characteristic 
of the acute form. There is exalted emotional excitement, at 
times sufficient to suggest acute mania and possessing the 
same peculiarities, the difference being in the severity of the 
symptoms, not in kind. The hallucinations are changing and 



MENTAL DISEASES. 413 

unsystematized; the moral sense is perverted or abolished; un- 
hinging in the sexual sphere is common. Recovery may take 
place, but the rule is termination in dementia within two or 
five years. 

CONFUSIONAL INSANITY. 

A rare form of insanity characterized by incoherence and con- 
fusion of ideas, without essential emotional disturbance or 
true dementia. It usually results from emotional shock, cere- 
bral exhaustion or excesses, and may follow severe acute dis- 
eases (as rheumatism, typhoid fever, diphtheria) or surgical 
operations. 

The patient experiences hallucinations and delusions which 
resemble those of acute mania or, oftener, of melancholia, but 
they do not affect the emotional life. Delusions of identity are 
common; for instance, a perfect stranger may be taken for an 
intimate friend whom he does not resemble at all; or he fails to 
recognize a street on which he has lived for years. The speech 
is characteristic. It is incoherent, hesitating, broken, confused. 
The words are enunciated with clearness, but there is startling 
irrelevancy, a complete absence of sense. This is undoubtedly 
the result of a true incoherence in ideation. 

The essence of the psychical state is "confusion;" the patient 
himself is vaguely conscious of this fact, speaks of it often, and 
enlarges upon the change which has taken place in him; later 
he no longer clearly recognizes his present condition. 

The general health in well-marked cases suffers, marked 
physical exhaustion being particularly conspicuous. The pulse 
is rapid and feeble; oedema arises from great vaso-motor weak- 
ness; the cutaneous reflexes and sensibilities are lessened; the 
bodily temperature is subnormal; the urine is excessively rich in 
phosphates, and there is progressive loss of weight. In some 
cases there is mild delirium, with the possibility of outbreaks 
of paroxysms of fury, not unlike those of acute mania. Some- 
times the delirium resembles that of subacute alcoholism, fear 
and tremulousness being pronounced. 

The prognosis is favorable. By far the greater number of 
cases — from 60 to 80 per cent. — recover, unless a serious organic 
disease prevents; recovery, however, is liable to be very slow. 



414 DISEASES OF THE NERVOUS SYSTEM. 

In a small proportion of the cases the mental disorder assumes 
a chronic form; in others death results from complications. 

Treatment —Here, as in all mental disorders, the patient 
should be sent to an asylum unless possessed of sufficient means 
to receive in his own home all necessary skilled attention. Ab- 
solute rest must be enforced, at least until the physical exhaus- 
tion has been largely corrected. Frequent and generous feeding 
is of the greatest importance; patients will readily digest a 
large amount of food; should resistance to feeding be offered, 
force is to be employed. A low bodily temperature being con- 
spicuous, the necessity of keeping the room very warm, of pro- 
viding thick and warm clothing, and of using all forms of ex- 
ternal heat (hot-water bed; hot packs) readily suggests itself. 

Aside from drugs which may be needed to insure sleep at night 
and to relieve delirious excitement, the treatment is symptom- 
atic, with particular reference to the cause of the mental dis- 
turbance. The use of large doses of bromides is especially ob- 
jectionable here because of the existing depression in the nutri- 
tive as well as in the functional activity of the nerve cells. 

TERMINAL DEMENTIA. 

This term is used to describe that permanent enfeeblement of 
the entire mental sphere which constitutes the conclusion of un- 
cured acute insanity. In some cases the primary disease passes 
directly into the dementia; in others through an intermediate 
stage of chronic secondary mania which is marked by confu- 
sion of ideas and mental decay; in the latter case the dementia 
is "tertiary." 

The terminal insanity of some forms of melancholia or that 
following violent outbreaks of maniacal furor is characterized 
by a perfect blotting out of mental life. The walk is shambling 
and cowering; the face wholly void of expression; speech con- 
sists of a few indistinctly spoken words; the habits are filthy; 
the patients are as helpless as little children, unable to attend 
to the commonest demands of nature. Death comes to their re- 
lief in a few years. Others are capable of discharging some of 
the simpler duties of life and may be utilized in the care of the 
farm and house, or even of the sick. Still others preserve some 
of the peculiarities of the primary disease, which may easily be 



MENTAL DISEASES. 415 

recognized. Thus, some are able to be about and feed them- 
selves, but are viciously dirty and become objects of disgust; 
others are quiet, passing the entire day without speaking a 
word or giving any evidence of the power of observation or 
thinking; still others are restless, noisy, talkative, destructive, 
all without purpose (active or agitated dementia, a sequel of 
mania and agitated melancholy). As Spitzka expresses it, "the 
fundamental feature of terminal mania is an acquired mental 
defect, and this may vary from a mere loss of memory, usually 
of recent events, or of the reasoning power, to the nearly com- 
plete extinction of mind." 

General nutrition in all these cases is good; the patients eat 
well, sleep well, and gain in weight. On the other hand, cuta- 
neous eruptions, hasmatoma auris, premature grayness, and 
fatty and fibrous disease of the blood vessels are common. 

NEUROPATHIC INSANITY. 

This term is used to cover such forms of insanity as depend 
upon, or are closely connected with, failure of development or 
faulty development of the nerve centres, inherited or acquired. 
If inherited, they are nearly always the result of a neurosis 
which started generations back, or of insanity or disease of 
the nervous system, drunkenness, syphilis, or extreme exhaus- 
tion of the vital powers of the parents by great poverty, priva- 
tion or long-continued severe illness. It can not always be 
positively ascertained where lies the beginning of this fateful 
inheritance, for, thanks to the compensatory efforts of nature 
by the introduction of new blood and the influence of new fac- 
tors, each generation undergoes modifications and changes 
which tend to weaken and finally overcome these inherited 
vices of constitution. 

Not-inherited aetiological factors are: severe, exhausting ill- 
ness during childhood and youth, breaking down the nervous 
system; exceptionally bad sanitary, hygienic and moral sur- 
roundings; injuries; sexual vices, acquired in childhood or dur- 
ing the period of pubescence; the varied influences which in the 
young develop faulty habits of mind and body; epilepsy and 
similar functional diseases of the nervous system; alcoholism; 
syphilis. 



416 DISEASES OF THE NERVOUS SYSTEM. 

Generally speaking, the pure insanities which result from an 
inherited neurotic taint or tendency are characterized by gen- 
eral and gross defect in brain development (as in idiocy); or 
they show anomalies in the shape of the cranium, its peri- 
pheral growth and innervation (as in cretinism, imbecility, 
original monomania); or in convulsions during childhood; or 
in a generally neurotic constitution and mentally abnormal 
character. The mental disorders may date from birth, or 
puberty, or second climacteric, or may be developed at any 
time of life by exciting causes. The ''neurotic vice" may be ac- 
quired through traumatism, poisoning (alcohol), or on the 
basis of such constitutional neuroses as epilepsy and hysteria. 
The pure insanities which are the expression of a continuous 
neurotic vice, but not dependent on the great neuroses, comprise 
idiocy, imbecility, cretinic insanity, monomania, and periodi- 
cal insanity. Those which are dependent on the great neuroses 
comprise epileptic, hysterical and alcoholic insanity. (Spitzka.) 
It is readily seen that an infinite variety of affections of the 
nerve centers and brain must be caused by this neurotic taint; 
these range from eccentricities of character to the most pro- 
nounced phase of mental aberration, the extent of the mischief 
done depending upon the extent to which the nervous system 
and the brain are affected. Further, if the harm done affects 
chiefly or entirely the intellectual sphere, the disorders arising 
belong to the disorders of the intellect; if the moral sphere, the 
result is a moral disorder and perversion, i. e., criminal ten- 
dency. 

This subject is both fascinating and almost inexhaustible. 

It deals largely with the "borderland" between sanity and 
insanity to which reference has already been made, and shows 
the gradual, scarcely perceptible shading from the merely ec- 
centric mind to the genius whose work endures for all time, 
from the harmless crank to the monster whose crime fills the 
world with horror. That the possible and frequent association 
of genius with insanity is based upon facts appears from even 
a superficial study of the life-histor}' of many brilliant men and 
women and of their antecedents, as to inherited neurotic ten- 
dencies. On the one hand such an examination clearly demon- 
strates the close relation between poetic ecstasy and a morbid 
imagination, between the heavenly vision and an insane delusion, 



MENTAL DISEASES. 417 

between martyrdom and the exaltation born of mental disease. 
On the other hand it enables us to find in the parents or grand- 
parents the first cause of the neurotic tendency -which has given 
to one descendant abnormal greatness, while to another it has 
bequeathed mediocrity, imbecility, or a heritage of woe and 
shame. 

The inherited tendency to the commission of crime is in itself 
of sufficient importance to merit the particular attention of not 
only alienists, but of all intelligent citizens. A thorough study 
of the question, which must here be ignored, leads to the con- 
viction that our present civilization has not yet grasped the 
real value of educational measures in dealing with crime itself, 
nor the relation of sanitary reforms and of careful observance 
of physiological laws to the existence and growth of the crim- 
inal classes. 

The most striking characteristics of moral insanity are the 
utter lack of perception as to right and wrong and the fre- 
quency with which sexual perversions are observed among 
this class. I happen to be familiar with the history of a 
peasant family (Marsch) living in the central part of Prussia 
about 1856 to '60, which illustrates the extent of the horrible 
possibilities of such a dreadful inheritance. The father died in 
middle age, without proof of any particular crime resting upon 
him; the mother, a confirmed thief, was sentenced to State prison 
for a term of years, when more than eighty years old, for having 
harbored murderers and thieves and for having received stolen 
property. One of the sons was sentenced to imprisonment for 
life for having murderously assaulted a comrade in the army; 
one sister killed herself in prison while undergoing trial for 
murder; another sister was beheaded, after having been found 
guilty of complicity in several murders, among them the mur- 
der of her husband by one of her brothers; another brother, 
physically, a perfectly formed specimen of a man, lived a life of 
unbridled crime, with every evidence throughout his career of 
remarkable presence of mind, executive ability and ingenious- 
ness. As a child he spent all his time catching birds for the pur- 
pose of tearing out their tongues and putting out their eyes. 
He became a rapist, regardless of the age or condition of his 
victims, and a murderer chiefly for the purpose of committing 
robbery or rape, in all cases showing extreme cruelty. His 
27 



418 DISEASES OF THE NERVOUS SYSTEM. 

reasoning powers were excellent. Hunted like a wild beast, in 
a thickly settled country, he managed by his adroitness, ad- 
dress, and presence of mind to avoid capture and, when a pris- 
oner, to dupe experienced officials and make good his escape. 
When recaptured and placed on trial for his life, he recited with 
the utmost coolness harrowing details of crimes almost beyond 
belief, and, with a single exception, without the slightest trace 
of compunction, feeling or the exhibition of any sign -which 
might justify the belief that he knew right from wrong. 

The sexual perversions which help form the sum total of 
moral insan^ may be in part due to evil associations and to 
the example of others, but in many cases there certainly is an 
inherited tendency which may express itself in some form very 
early in life, even in extreme youth and without the excuse of 
an evil example. The indescribable filth of sodomy occurs in 
this mania. 

PARANOIA. 

A form of mental disorder resting upon a neuropathic basis, 
inherited or acquired, usually accompanied with hallucinations 
and delusions which are more or less systematized. The neuro- 
pathic state may be the result of some disease or injury during 
early childhood. It is an essentially chronic affection and one 
of slow growth, though betraying all the while more or less 
clearly the constitutional vice. Sometimes a delirious or mani- 
acal attack may be the beginning of the fixed mental disorder. 
There are hallucinations, usually of hearing, less often of feel- 
ing, seeing, tasting, or smelling. Delusions may be accompa- 
nied by hallucinations or depend upon them. The disease prac- 
tically is incurable. Intermissions are frequent and prolonged, 
but not complete, the patient usually showing some traces of 
mental weakening or aberration which he may take considerable 
pains to hide. After a time, varying greatly in duration, he 
slowly drifts back into the old condition. Exacerbations also 
may occur, with considerable cerebral excitement, sleeplessness, 
sometimes ecstasy, delirium, stupor, etc. Again, the paranoiac 
may develop some other form of insanity, notably dementia 
paralytica. The termination usually is in a semi-dementia, in 
which the patient retains a part of the habits and training of 
his earlier life and enjoys making himself more or less useful 



MENTAL DISEASES. 419 

about the institution in which he happens to be; their condition 
is described as one of "physical weakness and good-natured 
stupidity." 

Early Paranoia develops in childhood, perhaps at the time of 
puberty (hebephrenia). It is not easy, usually, at this time to 
determine anything beyond the existence of the strongly 
marked neurotic tendency. The child is morbid, full of strange 
notions and fancies, unhappy, dissatisfied; such a condition, 
however, presents nothing characteristic, and may exist in 
those who are merely impressionable and not judiciously 
reared. Nevertheless, the presence of the strongly pronounced 
neurotic tendency attaches to such traits a much more serious 
meaning than they otherwise would have. Later, such children, 
as they grow into adolescence, are not thoughtful, considerate 
of others, open-hearted, womanly or manly, but sentimental to 
the last degree, have an exalted opinion of themselves, and, nine 
times out of ten, are inveterate masturbators. A state of more 
or less continuous hysterical excitement is common, and with it 
a strange and dominating craving to be pitied. To excite com- 
miseration is the chief object of life. I had under observation 
for a number of years a young girl, the illegitimate child of a 
woman of low moral tone and of a father who was notori- 
ously intemperate and shiftless. The child had been in charge 
of the County authorities, but at their earnest request was 
taken into a quiet, respectable home, with the hope that the 
girl, who had some pleasing qualities, might be made a useful 
and good woman. She was at that time about thirteen years 
old, and appeared to be happy in her new and comfortable 
home. She keenly enjoyed appearing on the street well dressed, 
readily adopted good manners, and behaved as well as could 
be expected. Her chief faults, lying and pilfering showy 
articles of slight actual value, were attributed to a lack of 
proper training and were readily forgiven, especially as she 
seemed thoroughly penitent when confronted with them. Dur- 
ing the year, or more, the girl lived in this family she could not 
be broken of these faults; yet, she seemed so contrite and so 
passionately grateful that she was pardoned again and again. 
A great annoyance to her new friends, and one that seemed in- 
explainable to them, were periods of personal neglect in which 
the girl, usually fond of being well dressed, appeared slouchy 



420 DISEASES OF THE NERVOUS SYSTEM. 

and dirty. Accidentally it was discovered that she mas- 
turbated. She was finally returned to the county authorities 
because she had nearly ruined the social standing of the family 
and the business of her protector by telling about town, in 
stores, on the streets, in the homes of people whom she was al- 
lowed to see, the most heart-rending stories about having been 
cruelly beaten, locked up in the cellar for trifling offenses, and 
being hung up by the thumbs and kept standing on her toes 
until almost dead from exhaustion. In making up these 
stories she showed much judgment; a bruise received on the leg 
in play would, for instance, furnish the basis for a harrowing 
tale of abuse, and would invariably be connected with some 
minor offense on her part of which she had actually been 
guilty, and which she frankly acknowledged and cited, seem- 
ingly for the purpose *of mitigating the cruelty practiced upon 
her. After a quiet but thorough investigation of her stories, 
she was finally, in the presence of the family and of County 
officials, asked to explain; she broke down, acknowledged that 
she had for months told these falsehoods, and finished by 
throwing herself upon the ground, clasping the knees of her 
protector, and in the most passionate manner begging forgive- 
ness, and praying not to be sent away. When asked why she 
had told these falsehoods, she explained that in all her life no- 
body had ever been sorry for her, and "she wanted people to be 
sorry for her." 

Growing into years of maturity, youthful paranoiacs do not 
acquire the strength of character which belongs to their years, 
but remain in a state of incomplete development. 

In the so-called late paranoia, the eccentric and irresponsible 
state already described has continued, imperceptibly increasing 
until a fixed delusion has taken possession of the patient or un- 
til after some acute disease which has still further weakened an 
already enfeebled and unstable netvous system, there suddenly 
sets in acute mania or delirum. This is usually the delirium of 
persecution; unlike the melancholic, the paranoiac here is 
liable to become dangerous. He is conscious of innocence and 
ready to turn upon his persecutor or persecutors, to defend or 
revenge himself. Hallucinations precede and accompany this 
state, usually of hearing, but also of feeling, taste and smell, 
rarely of vision. The delusion may assume other forms. Thus 



MENTAL DISEASES. 421 

he may fancy that his property rather than his person is en- 
dangered; if at large, such a person is constantly engaged in 
law suits, and his animosity toward judges and juries who de- 
cide against him may become a domineering passion and lead 
him into trouble. Or his condition may assume the form of a 
religious insanity; he may then hear heavenly voices and see 
visions. In all these forms the sexual element is strongly 
marked, especially so in the religious type of paranoia, and 
masturbation is nearly always a ruling passion. If the mental 
disorder takes a sentimental turn, it is likely to prove an erotic 
paranoia, a love, almost always returned, for some exalted 
person, with erotic exaltation and dreams. The religious ele- 
ment may assert itself in connection with this type, and then it 
gives rise to painfully disgusting fancies of physical love for 
sainted spirits in whose arms the subject rests all night. Grad- 
ually a state of permanent mental enf eeblement obtains, often re- 
taining in a less aggressive form the characteristic delusion. As 
stated, this class of patients in an asylum are frequently help- 
ful and usually good-natured, although their freaks often ren- 
der them a source of constant annoyance to those in charge. 

PERIODICAL INSANITY. 

The distinguishing feature of this form of insanity lies in its 
occurrence at regular or irregular intervals, with periods of a 
comparatively normal mental state between the paroxysms. 
To this form belong the true neuropathic dipsomania, epilep 
tic insanity, menstrual insanity, periodical melancholia. All 
rest upon a neuropathic basis. 

The successive attacks of periodical insanity resemble each 
other closely, and sometimes are faithful reproductions of the 
same picture of mental confusion, even to the language em- 
ployed. They may be preceded by certain vague premonitory 
symptoms or may be sudden in onset, accompanied with illu- 
sions, hallucinations and delusions; there are also present such 
indications of severe implication of the general nervous system 
as: congested face and headache, cold hands, palpitation of the 
heart, sleeplessness, and defective vision. The delirium may be 
very violent and is often tinged with evidence of sexual de- 
pravity; yet, though noisy and demonstrative, the patient may 



422 DISEASES OF THE NERVOUS SYSTEM. 

commit no serious offense. Frequently, however, a morbid im- 
pulse asserts itself and becomes an imperative act through the 
commission of some crime (burning a house; some sexual 
crime, usually horrible; murder; suicide). 

During the interval between the attacks the patient may ap- 
pear perfectly rational, take care of himself, his family, and his 
business affairs. But in the long run his condition becomes one 
of gradual, though not rapid, physical and mental failure, with 
more or less instability and irritability of the nervous system. 

The term cyclothymia or circular insanity is used to describe 
the occurrence of mental disease in cycles which are completed 
in a few days or in months, the general rule obtaining that the 
more severe the symptoms, the shorter the cycle. The arrange- 
ment of these cycles differs in different cases, but is the same in 
the one individual case. The cycle may begin with a mania; the 
patient may then pass through a melancholia, then have a lucid 
interval. The passage from one to the other is usually gradual, 
sometimes abrupt. Lucid intervals may be wanting. The par- 
oxysms of mania or melancholia do not in any sense, including 
lightness or severity, differ from any other attacks of mania 
or melancholy; it is only the arrangement in regular cycles 
which constitutes the form or type. 

In very light cases the patient may simply be considered 
moody or irritable and unreliable, on account of the constant 
change in his mental condition and attitude, since there is noth- 
ing in his daily life or conduct to warrant the presumption that 
he is not sane. 

THERAPEUTICS OE INSANITY. 

Aconite. Mental disorders from fright, chagrin, anger, joy, 
and from over-heating. Great mental anxiety and general high 
tension, both mental and physical, marked by over-sensitive- 
ness. He is peevish, irritable, malicious; cannot endure music, 
it drives him wild; fear of a crowd, of the dark, great fear of 
death. Constant and excessive anxiety. Sleeplessness. Mania 
with fitfulness; alternately laughs and cries. Symptoms of 
moderately active congestion; muscular pain and soreness. — 
Agaricus. Absorbed in his fancies; sings, laughs, talks to him- 
self, answering no question. Confused; can't find the right 



MENTAL DISEASES. 423 

word; wants to be let alone. Mental trouble from worry, from 
mental excitement. Dementia from palsy. Expansive delusion. 
Melancholia, with tendency to do violence. Epileptic insanity, 
with frenzied delirium, with spells of religious mania. Great 
muscular strength; jactitation of muscles; violent spasms, 
tonic and clonic. Sad, anxious moods; imbecility. — Anacar- 
dium. Both mental and bodily operations sluggish. Fearful 
and apprehensive; thinks he is surrounded by enemies; dull, 
stupid despair, cowardly, ill-natured, cruel. Hallucinations of 
hearing; he hears voices which sound to him as though far 
away. Anthropophobia. Mental trouble in connection with 
brain-fag. Dementia of old people with rapid loss of memory 
and mental vigor. He moves about as though half-drunk. — 
Argentum nitricum. Mental and physical prostration; lack 
of will-power; loss of memory, he cannot find the right word; 
fancies himself an object of general contempt, his own family 
included; dreads being alone, gets nervous and must have some 
one to talk to him; is afraid of being too late; hurried in all he 
does. Hypochondriasis; melancholia; fixed delusions; predicts 
time and manner of his death; wants to kill himself, but is 
too cowardly to do it. Epilepsy; tendency to fall sideways. — 
(Arg. metaleicum. Restless; wanders about aimlessly; spasm 
when entering a warm room from the open air; before mid- 
night; when asleep at night.) — Arsenicum. Of the greatest value 
when mental disturbances arise from the exhaustion following 
bodily disease, overwork, loss of sleep; often from a badly 
nourished condition of the system, the result of gastric trouble 
of long standing. The mental condition is one of apprehensive- 
ness, restlessness, uncontrollable anxiety. He is ill-humored 
and quickly takes exception' to everything said or done; he is 
irresolute, peevish; is afraid of everything; cannot sleep at 
night and becomes so restless and anxious that he goes from 
bed to bed trying to find relief. Hallucinations (ghosts, 
thieves, vermin, bad smells, like sulphur). Religious insanity, 
with despair. Suicidal mania (hanging?) determined, the desire 
to kill himself being the result of the actual suffering he under- 
goes. Characteristic constitutional indications are present, as: 
exhaustion; quick, irregular, weak pulse; sensation of burning 
pain in stomach and bowels; burning like fire at the anus; ag- 
gravations from being indoors and at night; relief from being 



424 DISEASES OF THE NERVOUS SYSTEM. 

out of doors, from warmth. — Aurum. The emotional sphere is 
greatly disturbed; the mental derangements which call for its use 
are closely associated with grief, vexation, disappointed love, 
and similar depressing emotional factois. The patient is tearful, 
hysterical, vehement, impatient, unstable; he cannot bear sym- 
pathy or contradiction; has no confidence in himself and feels 
that nobody else has, yet he finds fault with everybody; he 
asks questions, but does not wait for the answer. Inclined to 
religious melancholy of mildly emotional type, with constant 
praying. Nervous and easily frightened; the least noise startles 
him. There is suicidal mania, but it is emotional; while the pa- 
tient sets about finding means to kill himself, he is irresolute 
and does not actually accomplish it. With these there is rest- 
lessness at night, rush of blood to the head, palpitation of the 
heart, and, often, violent sexual desire, sometimes almost an 
amorous frenzy, with frequent pollutions. Vertigo is common. 
The patient is well nourished;, his symptoms are liable to be 
worse at the full of the moon; he is better in the open air and 
from out-door exercise. Affections arising from mercurial or 
syphilitic poisoning, hypochondriasis, melancholia. — Bella- 
donna is of great value in acute mania. The delirium is furious 
and accompanied with every symptom of intense cerebral con- 
gestion. One of the characteristics of the Belladonna patient 
is the frequent and rapid change of mood; one moment he fran- 
tica% strips himself of every bit of clothing, froths at the 
mouth, bites, screams and plays the demon; the next he is bois- 
terously merry. There is excessive excitability of the senses; 
hallucinations of vision are common; he sees dogs, fire, mon- 
sters, etc., in the room. Also useful in melancholia with mental 
dullness, heat of the head, full pulse, sleeplessness, etc. Less 
often indicated in epileptic insanity.— Calc area carbonica. 
Limited, largely, to milder forms of mental enfeeblement of a 
temporary character, resulting in great apprehension of com- 
ing evil, including insanity, with ringing and roaring in the 
ears, offensive smell in the nose, sleeplessness, with horrifying 
dreams of dogs, corpses and death, general despondency, weak- 
ness of memor}-, bodily feebleness. In women, with character- 
istic constitutional indications.— Cannabis Indica is occasion- 
ally useful in hypochondriasis, with illusions concerning the 
state of one's health; he fears that he is going to die or become 



MENTAL DISEASES. 425 

insane; watches all his symptoms with anxious concern; gas- 
tric derangement, flatulency, cold extremities. Also indicated 
in puerperal mania with constantly and rapidly changing hal- 
lucinations; incoherency; laughs at everything said or done; 
forgets what she was about to say, so cannot finish the sen- 
tence, has no appreciation of time or space; voices sound as 
though far away; everything appears unreal. Exaltation of 
mind and high-flowing language. — Cantharides. Acute mania 
with sexual frenzy, not so much due to excitement of the imag- 
ination as of the sexual organs; the patient suffers intensely 
from constant sexual erethism, demanding immediate gratifica- 
tion. Paroxysms of rage, with crying, barking, even convul- 
sions. Frequent micturition, often painful.— Conium. Melan- 
cholia in older people, with inability to endure excitement, to 
make a prolonged mental effort, to recollect. Weak sexual 
power, with pollutions; nervous system deranged from continu- 
ous sexual desire, the gratification of which circumstances do not 
permit. Desire for solitude, yet does not want to be left alone. 
Folie circulaire. Uterine and ovarian affections.— Digitalis. 
Exceedingly valuable when the slowness of the pulse in mental 
disorders is such as to attract attention. There is exhaustion, 
debility, throbbing headache. The mental symptoms are not 
characteristic (depression, moodiness, anxiety, weakness of 
memory, aggravations from music), but it has proved a useful 
remedy in asylum practice. — Glonoine. Acute mania, with 
violent headache, with heat, fullness and throbbing in the 
head, staring eyes, throbbing of the carotids, etc. Expansive 
delusions; thinks he is God. After exposure to the heat of the 
sun.— Hyoscyamus. Intense hysterical excitement, with exces- 
sive talkativeness, laughing and singing. Puerperal mania 
with sexual excitement and fear of being poisoned. Acute 
mania, with a highly excited state of the sensorium and many 
abnormal impulses, rage, fury, with exhibition of great muscu- 
lar strength. Strongly marked convulsive action; pharyngeal 
spasms, so he cannot drink. Lasciviousness and shameless- 
ness from cerebral excitement. Epileptic insanity. — Kali 
bromatum. Acute mania, with sleeplessness, fear of being 
poisoned, of being pursued, etc. Suicidal mania, with tremu- 
lousness and twitching of muscles. Brain-fag, with a sense of 
numbness in the head and feeling as though he would lose his 



426 DISEASES OF THE NERVOUS SYSTEM. 

reason. Loss of memory, a kind of aphasia in which words 
and syllables are forgotten and omitted.— Lachesis. In men- 
tal disorders in women who are passing through the change of 
life; melancholic tendency, always looking upon the dark side; 
changeable, peevish, notional; cannot keep her mind fixed upon 
anything; continuous mild restlessness, physical and mental. 
Apprehension of coming evil; fear of death, yet talks about 
committing suicide; thinks she is dead and about to be buried. 
Lasciviousness. Mania with excessive talkativeness. Thinks 
she is under divine control. Sexual desire of cerebral origin, 
with weakness of the genitals. Characteristic general indica- 
tions are present, as the inability to wear anything tight 
about the throat.— Lilium tigrinum is very useful in the intense 
hysterical excitement of the nervous system which occasionally 
accompanies uterine or ovarian disease. Sexual desire is 
usually abnormally active and is largely responsible for the 
coloring of the symptoms. She is rendered wretched by it, and 
is forced to keep herself constantly employed not to lose con- 
trol of herself; she is unstrung, "hurried" in whatever she does, 
and with it unable to fix her mind upon any one thing long 
enough to accomplish much; the irritability of the nervous sys- 
tem is such that she grows impatient and desperate and is in 
constant danger of explosions of profane and unbecoming lan- 
guage. Frequently present in such cases is a sensation of bear- 
ing-down, as though the pelvic contents would issue from the 
vulva unless prevented by upward pressure of the hand. There 
is usually thin, brown, acrid leucorrhcea.— Nux vomica, though 
of constant use in the treatment of the insane, finds its most 
important field of employment, not during delirious or mani- 
acal paroxysms, but during comparatively lucid intervals and 
in the chronic forms of mental derangement where its action upon 
the digestive system frequently demands its exhibition. It is 
particularly adapted to cases in which chronic alcoholism is a 
prominent aetiological factor and where the disposition of the 
patient is cross and aggressively irritable. Constipation, haem- 
orrhoidal troubles and dull headaches are commonly present. — 
Opium. Melancholia. Mania. Flushed face, cold extremities, 
eyes wide open, frightful illusions, giving rise to attempts to 
escape. Or, after the spasm, unconsciousness; face pale; eyes 
half-open, glassy; sighing respiration; sopor, with snoring; 



MENTAL DISEASES. 427 

profound coma. — Platina. In mania of women, associated 
with terrible sexual excitement and expansive delusions. She 
feels superior to all about her and treats everybody with con- 
tempt. Vacillating; now mirthful, in an hour depressed and 
tearful. Thinks she is going to die. Great precordial anguish. 
Frightful illusions; sees ghosts. Numbness, coldness in the ex- 
tremities; sensations of "crawling" here and there; menorrha- 
gia; characteristic gastric symptoms. Constipation. Puerperal 
mania.— Stramonium. Resembles Belladonna and Hyoscy- 
amus, but has less cerebral congestion and is marked by a 
greater tendency to incessant talking. There is constant talking, 
laughing, and singing. He has wild delirium, with terrifying 
hallucinations, hence frantic attempts to escape. Constantly 
afraid that harm will be done him; does not want to be let 
alone in the dark. Melancholia; afraid he will die; thinks he 
will be damned. Complains of sensation of lightness in the 
head. The face is red and bloated; the eyes staring, with dilated 
pupils which are insensible to light; lips and tongue tremulous; 
difficulty of swallowing; convulsive twitching of limbs; sup- 
pression or involuntary escape of urine. — Yeratrum album. 
Mania and melancholia with stupor. Feels that he has com- 
mitted a great crime; will be damned eternally. Delirium of 
grandeur; delusion of being afflicted with loss of sight and 
hearing; thinks she is pregnant or in labor. In melancholia; 
utterly hopeless; sits in a chair, the head sunk upon the chest, 
paying no attention to anything, answering no questions, tak- 
ing neither food nor drink unless forced upon her. Fainting- 
spells. Pulse weak, intermitting; face pale, nose cold and 
pointed, cold sweat on face and forehead; eyes sunken, with 
dark circles around them; bodily surface cold and bluish. — 
Zincum metallicum. Thinks he has committed a great crime 
and is about to be arrested for it; tries to commit suicide in 
order to escape the consequences. Melancholia; lethargy; ten- 
dency to twitching of muscles and convulsions; paralytic 
numbness and weakness in the extremities. Chorea. Locomo- 
tor ataxia. Epilepsy. 
Consult also: Agnus castus, Asa fcetida, Causticum, 

ClCUTA, ClMICIFUGA, COCCULUS, CROTALUS, CUPRUM, GELSE- 

MruM, Helleborus, Ignatia, Laurocerasus, Moschus, Naja, 
Natrum muriaticum, CEnanthe crocata, Phosphorus, 



428 DISEASES OF THE NERVOUS SYSTEM. 

Picric acid, Plumbum, Psorinum, Pulsatilla, Sepia, Stan- 
num, Sulphur, Thuja, Veratrum yiride. 

Any of these may be found indicated by their close relation to 
the primary physical cause of the mental derangement or by 
their ability to relieve or remove bodily ailments which directly 
or indirectly aggravate the mental condition of the patient. 



GENERAL AND FUNCTIONAL DISEASES. 
NEURASTHENIA. 

Neurasthenia (Beard), Nervous Weakness, Nervous Irritable 
Weakness, is simply an exhausted condition of the nerve cen- 
tres which does not depend upon organic disease. In very 
many cases a predisposition to such a state is inherited from 
parents who themselves are of a neurotic tendency; in others it 
is acquired, usually early in life, by privation, overexertion or, 
oftener, by vicious habits, as masturbation. Whatever lessens 
nerve-force must be considered a predisposing cause of neuras- 
thenia. Given a state of enfeeblement of the nerve-centres, no 
especial harm may come if in after-life no demands are made 
upon the subject beyond those which the state of his nervous 
system allows him to meet; when the demands made are larger 
than can be met, a "crash" results, the expressions of which are 
all grouped under the term neurasthenia. The immediate cause, 
usually, is overwork — the term being used relatively — particu- 
larly under unfavorable circumstances, such as anxiety about 
Family affairs or business matters. 

Symptoms. — Neurasthenia, like its first cousins h\ r steria and 
hypochondriasis, is a complex condition and presents a great 
variety' of symptoms. In the larger number of cases certain 
local symptoms stand out with sufficient prominence to attract 
special attention, constituting types; hence the recognition of 
cerebrasthenia, spinal neurasthenia and sexual neurasthenia, all 
these in the main resembling each other, but each characterized 
by particular prominence of symptoms within a certain sphere. 

The affection is insidious in its development. Occasionally 
some particular occurrence, as an attack of vertigo, is the first 



GENERAL AND FUNCTIONAL DISEASES. 429 

indication that serious trouble has commenced. If careful in- 
quiry is made, it is found that the patient for some time has 
experienced weariness of body and mind, inability to perform 
the daily tasks of business, difficulty in attending to the small 
duties of life, or in fixing the attention, in adding sums, in at- 
tending to correspondence, and in getting refreshing sleep at 
night. In cerebi -asthenia these are particularly marked; there 
is much irritability, impatience, moodiness and mental depres- 
sion. Often the head feels full, with a pressive, clamp-like pain, 
frequently in the occipital region; but headaches are by no 
means constant. For a long time, when the mental symptoms 
are quite pronounced, there is ability to endure considerable 
physical exertion, and it is not uncommon to experience relief 
of mind from manual employment; but soon the patient tires 
easily and cannot be induced to exert himself. Weakness of 
sight is common, the eye tiring easily, and sleeplessness event- 
ually, in the greater number of cases, becomes habitual. In the 
so-called spinal neurasthenia (spinal irritation) there may 
be, in addition, considerable aching and sense of lameness in the 
back, often with tender spots along the spine, easily discovered 
by pressure. Weariness and weakness of the legs is at times 
excessive, with a feeling of -weight as though they were too 
heavy to be dragged along. Aching in the legs, numbness, and 
tingling are common. The tendon reflexes are increased. There 
is vaso-motor weakness, as shown by flushing of the face, waves 
of heat all over, sometimes excessive sweating from slight 
causes. In many cases the hands and feet are constantly cold 
and damp, and there may be night-sweats. There is also irri- 
tability of the heart, with a tendency to palpitation and short- 
ness of breath. The pulse is rapid, irregular, intermittent, 
easily upset. Arterial throbbing may be visible almost as 
plainly as in aortic insufficiency, and forcible pulsations in the 
epigastrium may suggest abdominal aneurism. In sexual neu- 
rasthenia the mental condition is one of great depression and 
cowardly apprehensions of all kinds. Sexual weakness is pro- 
nounced, and the patient keeps himself in a state of misery by 
habitually contemplating the hopelessness of his condition, as 
it appears to him. Lack of power to perform the sexual act 
often results from sheer apprehension of failure, and completes 
his abject wretchedness. 



430 DISEASES OF THE NERVOUS SYSTEM. 

Atonic dyspepsia, itching, formications, sensory disturbances, 
liabilit}^ to periods of hysterical excitement or depression, and 
in many cases frequent and severe attacks of neuralgia, are 
usually present. The urine is concentrated and scanty, and 
s^miptoms of lithaemia may be conspicuous. The patient may 
be worn and haggard; often, however, neurasthenics are in 
good flesh; in fact, some of the worst cases I have seen were 
well-nourished and to the casual observer would have appeared 
am r thing but the wreck they were. 

The diagnosis is easily made. It rests largely upon negative 
evidence, i. e., the absence of organic diseases, as of the heart. 

The prognosis is favorable, recovery under proper treatment 
being the rule, even though the successful management of a 
case requires much tact and patience when there is great men- 
tal depression and sexual weakness. 

Treatment. — If the physician is consulted when the patient is 
still able to be about and is conscious of the overdraft he is 
making daily upon his strength, and of the results likely to 
follow, the treatment is simple and efficacious when honestly 
carried out. It consists of affording the nervous system rest 
by spending an hour, or two, daily in open-air exercise, prefer- 
ably on the wheel, boating, or, if accustomed to the saddle, 
horseback riding, with cold shower baths in the morning, fol- 
lowed by brisk rubbing, a good nourishing diet, and a few 
weeks passed in the county. 

But most cases do not come under medical care until far ad- 
vanced, and then they are much more difficult of management. 
Here, as in the treatment of the early stages of mental disor- 
ders, the success of treatment will depend largely upon tact on 
part of the medical man and upon his ability to show a kindly 
and honest sympathy without yielding in firmness. This ap- 
plies particularly to the sexual neurasthenic, who in reality 
often is a great sufferer. In such cases, after listening to the 
patient's familiar story and assuring him of the sympathy 
which he has a right to claim, I believe it to be the part of 
wisdom to assure him in the plainest terms possible that it is 
in his power to get well, certainly to make very material im- 
provement, if he cares to get well and will follow directions im- 
plicitly and to the very letter; but that treatment is a waste 
of energy, time, and money unless he will honestly second every 



GENERAL AND FUNCTIONAL DISEASES. 431 

effort of the physician and endeavor to help himself by the use 
of common sense and pluck. 

Rest must, first of all, be secured; to this end absence from 
business, with an out-door life, is of the greatest importance. 
In seeking to provide this, it must be remembered that the pa- 
tient demands to be agreeably entertained and must not be al- 
lowed to get lonely or tired. The temptation, in case of well- 
to-do people, is to seek rest in travel; usually, with Americans, 
this means a frantic rushing from place to place, to return 
home, after a few weeks' absence, in a condition of exhilara- 
tion, soon to relapse into a worse state than that for which re- 
lief was sought; occasionally the disastrous results of such folly 
overtake them on the journey. The only way in which bene- 
fit maybe had from travel is to avoid large towns and popular 
resorts, and spend a few weeks or months in a quiet, healthful 
spot, if possible in the open air, resting a good portion of the 
time, and taking just enough active exercise to maintain a 
good appetite for plain food and to insure restful sleep. The 
particular spot selected should, if possible, afford such oppor- 
tunities for indulging in out-of-door sports (fishing, hunting, 
sailing, etc.) as the patient likes. 

In very bad cases the so-called "rest cure," consisting of ab- 
solute rest in bed, forced feeding and passive exercise, continued 
from three to six weeks, promises much; it at least will give 
the patient a start when other means fail, and under continued 
medical care will make a permanent cure possible. This treat- 
ment is best obtained in some private institution, such as can 
now be found throughout the country. It may, however, be 
had at home, if circumstances are favorable. To be successful, 
there must be absolute isolation of the patient from his friends 
and constant attendance of a capable, experienced nurse. The 
diet is to consist chiefly of milk, given at frequent intervals, 
later varied as circumstances justify; meat must be excluded, 
but after a time meat-broths may be allowed. The aim is to 
give all the food the patient can bear without deranging 
stomach or bowels. Massage is to be administered daily, and 
ability to do this skillfully is one of the necessary qualifications 
of the nurse. Electricity (faradism) must also be used daily. 
Each muscle of the extremities and trunk must be firmly con- 
tracted by applying the poles to the motor points of each 



432 DISEASES OF THE NERVOUS SYSTEM. 

muscle, using a slowly interrupted current for about thirty 
minutes; then general faradization is had b} r applying one 
sponge electrode to the nape of the neck, the other pole to the 
feet. A rapidly interrupted current of fair strength is thus 
used for 15 to 20 minutes. The electrical treatment should be 
rapidly withdrawn after some weeks, but massage is to be 
kept up for a considerable length of time. 

The selection of remedies, here as in all functional diseases of 
the nervous s\ T stem, requires unusual care in the study of 
minute symptoms and close familiarity with the materia 
medica. The following hints may prove of service: 

Agaricus. Weak, irritable, anaemic spine, very sensitive to 
touch, usually with sharp, sticking pains; muscular twitchings. 
Neuralgic pains in different parts of the body, sharp and stick- 
ing or lightning-like. Severe neuralgic headaches, in a small 
spot, as though a nail were being driven into the head. Irri- 
table heart from the use of tobacco, tea, coffee. Numbness and 
formication in the extremities. Great sexual desire, with re- 
laxation of the male organ and great exhaustion following an 
embrace. Urine voided in small amounts. — Aurum. Melan- 
cholia; cardiac oppression; palpitation of the heart; irregular- 
ity of the pulse; severe headaches, as though the cranium were 
involved, with pressure outward, fullness and roaring in the 
head, much worse at night. Suspicion of syphilis. Old people. 
— Calcareacarbonica. An excellent remed}' when its peculiar 
constitutional indications are present. Patient is usually of 
fair complexion, large, flabby; easily tired from exertion, even 
though he appears well nourished. Sluggishness of functions; 
perspires easily and copiously; his feet are cold and damp. 
Memory seems to fail; heat in the head from any intellectual 
effort; fears he is losing his mind; easily confused; obstinate. 
Characteristic indigestion is often marked. — China. Anaemia 
from loss of fluids. Exhaustion which results from sexual ex- 
cesses. Low-spirited, gloomy, disinclined to make any mental 
effort. Profound apathy, or great irritability, with weakness. 
Rapid emaciation, with voracious appetite, indigestion, night 
sweats. Intense throbbing, anaemic headaches, with hammer- 
ing and beating in the head, roaring in the ears, hardness of 
hearing, Spine irritable, sensitive to touch; sharp pains ra- 
diating from the spine, chiefly into the head. — Coca. Given in 



GENERAL AND FUNCTIONAL DISEASES. 433 

physiological doses, it has proved valuable when there is gen- 
eral atony of the system. Cannot eat, sleep, or do any bodily 
or mental labor because he is too weak. Atonic dyspepsia. 
Weakness of the heart; it palpitates from slight cause; oppres- 
sion at the heart; both palpitation and oppression brought on 
readily from gastric flatulency. His weakness shows itself even 
in his voice. Cannot rest anywhere. He goes to bed com- 
pletely tired out, but cannot go to sleep. — Cocculus. Nervous 
exhaustion with heaviness and numbness of the entire body, 
especially the legs; spinal irritation, with hyperesthesia of all 
the senses; stupid; slow of comprehension; cannot find the right 
word to express himself. Vertigo, with stupid, heavy feeling in 
the head, often with great sickness at the stomach, total aver- 
sion to food, vomiting; intestinal flatulency. Melancholia. 
Cannot bear the least excitement. Ill effects of long-continued 
inability to sleep. Spells of overpowering sleepiness. — Gelse- 
mium. Great loss of muscular power; trembling from any ex- 
ertion, as walking or playing on the piano. Neuralgia, with 
loss of power in the affected parts. Great "weakness of the 
sexual organs; emissions without erections. Frequent head- 
aches with dizziness, confusion and sense of heat in the head, 
blurred vision, cold feet, muscular unsteadiness. — Ignatia. Par- 
ticularly useful in cases where there is a tendency to hysteria; 
the erratic, contradictory character of all the symptoms is well 
marked. Extreme sensitiveness to pain. Clavus hystericus. 
Characteristic indigestion -with craving for indigestible articles, 
"sinking" sensation at the epigastrium, great flatulency. 
Copious urination, especially during and after periods of emo- 
tional excitement. Melancholia. Sharp, stitching pains in the 
spinal cord, sometimes like lightning in suddenness of appear- 
ance and in severity. — Kali bromatum. Brain-fag, with heavi- 
ness and numb feeling in the head; thinks he will go crazy. 
Cerebral anaemia, with coldness of feet; melancholia, irrita- 
bility, hysterical weeping. Loss of memory, impaired coordi- 
nation, numbness and tingling in the extremities, resulting from 
sexual excesses. — Natrum muriaticum. Brain-fag, with im- 
paired memory, anaemia, depression of spirits, palpitation and 
sense of coldness about the heart; inability to fix the attention; 
melancholia; irritability , with paroxysms of weeping; hopeless- 
ness; chilliness; restlessness. Headache, usually frontal, sorae- 
28 



434 DISEASES OF THE NERVOUS SYSTEM. 

times occipital, in the morning, on waking. Backache; the 
back feels as though broken; paralytic weakness of the legs. 
Sense of weakness at the stomach; weakness in the abdominal 
muscles. Characteristic constipation. — Nux vomica. Patient 
is easily fatigued, both in mind and body; must often lie down 
and rest. Indescribable anxiety and nervous tension which 
gives him no rest, especially after being up late at night. Pas- 
sionate, jealous, easily angered disposition. Characteristic 
headache, gastric and intestinal symptoms, especially in habitual 
drunkards; atonic dyspepsia; constipation; haemorrhoids. Lum- 
bago; back sore and bruised. Spinal irritation, with paralytic 
weakness in the legs, which go to sleep easily, feel cold, appear 
bluish. Numbness and formication in the spine. Aggravations 
from being up late at night and from mental exertion; relief 
from sleep, but great aggravation from broken sleep. — Phos- 
phorus. Great mental and physical exhaustion, with tremb- 
ling in the limbs from weakness, and vertigo. Brain-fag, with 
sense of weariness and of coldness in the cerebellum. The brain 
is tired as though it never would get rested. Weariness and 
painful sensitiveness in the lower spine. Spinal irritation with 
burning pain between the shoulder blades. Ataxic symptoms. 
Mental effort is followed by shocks in the head. Paralytic feel- 
ing in the legs, causing awkward, stumbling gait. Weakness 
of the sexual organs; yet, he is burning up with sexual passion, 
has voluptuous, erotic dreams. Has an exalted opinion of him- 
self. — Phosphoric acid. Exhaustion of the cerebro-spinal nerv- 
ous system from overwork; is not able to make any mental 
effort, it exhausts him so completely; the hair turns gray early 
and falls out. Effects of mental shock and grief (disappoint- 
ment in love). Remarkable weakness of the sexual organs, 
usually from excessive indulgence, with weakness and burning 
in the spine, paralytic weakness of the legs, and escape of semi- 
nal fluid from the relaxed genitalia during sleep or after urinat- 
ing. SpinaPanremia from sexual excess, with pain in the vertex, 
palpitation of the heart, impotemry, etc. — Picric acid. Brain- 
fag; every attempt to perform mental labor brings on severe, 
throbbing headache at the base of the brain and complete 
letting-down of the whole system. Great weakness of the back, 
bodily weariness, paralytic heaviness of the legs. Loss of sex- 
ual power. Frequent seminal emissions, followed by general 



GENERAL AND FUNCTIONAL DISEASES. 435 

exhaustion and aching at the base of the brain. — Platina. 
Indicated in rare cases by characteristic sexual symptoms, i. e., 
satyriasis and nymphomania, with profound melancholia, asso- 
ciated with notions of grandeur, and inability to find sleep, due 
to the general nervous excitement. — Selenium has given good 
results in the treatment of the exhaustion following sexual ex- 
cesses, particularly of older men; voluptuous dreams, with 
quick emission of thin seminal fluid, followed by backache and 
great prostration. — Sulphur may in rather exceptional cases 
be called for by persistent constipation, with dryness and irri- 
tability of the rectum, burning soreness at the anus, congestive 
headache and engorgement of the liver. Its mental condition 
is one of irritability, sometimes with periods of mental indo- 
lence. Religious melancholia; abdominal plethora. 

Consult also: ^Esculus, Anacardium, Argentum nitricum, 
Arsenicum, Calcarea phosphorica, Cimicifuga, Coffea, 
Graphites, Plumbum, Pulsatilla, Silica, Zincum, and the 
remedies discussed under " Hysteria." 

HYSTERIA. 

A disordered condition of the nervous system in which there is 
exaltation of the emotional nature and depression of the will- 
power, giving rise to a perplexing variety of functional de- 
rangements which often closely resemble organic disease, but 
are not found to rest upon visible anatomical changes. It has 
been termed a psychosis. According to Moebius, it is a state 
in which ideas control the body and produce morbid changes 
in its functions. 

Etiology. — Hysteria is very largely a disease of women, or 
rather of females, chiefly because of the greater sensitiveness of 
their nervous organization; many cases, however, occur 
among boys and men. It usually appears near the age of 
puberty, but is often seen much earlier and quite late in life. 
Race peculiarities and civilization axe important factors. The 
Latin races, on account of their more highly developed emo- 
tional nature, are oftener the victims of hysteria than the more 
phlegmatic and self-contained peoples, like the English, and 
the affection assumes among them a far more serious aspect 
than it does among, say, the Teutonic races. The artificial 
life of a highly civilized people also favors the development of 



436 DISEASES OF THE NERVOUS SYSTEM. 

hysteria; it is practically unknown among savages. The 
effect of heredit}- is unmistakable. The children of neurotic 
parents, of persons who are epileptics, neurasthenics, in- 
sane, or sufferers from other forms of nervous disease, 
furnish a very large proportion of victims. In many 
cases a false system of education either helps develop this ten- 
dency or creates a predisposition to it. The long hours of 
study in the close school-room; the lack of abundant exercise 
in the open air; the silly "babying" to which many children are 
accustomed; the development of a prematurely active and, 
usually, false emotional life which of recent years has become 
the fashion; the fostering of social ambitions at a time of life 
which should be devoted to sound educational purposes and to 
the building-up of a vigorous body; the unwillingness to have 
children and young people realize the necessity of bearing re- 
sponsibilities and burdens, — all these prepare the subject for 
disorders of which hysteria is the most common expression. 
Proper training, especially the enforcement of implicit obedience 
to the commands of parents, has a tendency to repress and 
eradicate a predisposition to these affections. Whatever 
weakens or unduly tires the nervous system may excite lis- 
teria; here belong over-work, pain, depressing emotions and 
violent excitement, any one of which by one grand psychical 
storm may suddenly terminate in a severe paroxysm, or by a 
long series of less violent emotions may undermine and finally 
break down an already enfeebled nervous system. Physical 
causes, as an injury or the weakness resulting from severe ill- 
ness, may have the same effect. 

Epidemics of hysteria are not uncommon; they have swept 
over large territories of country and, especially in the middle 
ages, have helped make history. 

Symptoms. — All writers acknowledge the great difficulty of 
presenting a clear, concise, and yet reasonably complete picture 
of this many-sided affection. 

Convulsions occur in a large number of cases; of these, two 
forms are recognized: the minor form and the major form. The 
minor form of convulsive hysteria usually results from emo- 
tional excitement. It is frequently preceded by a "warning" or 
aura, consisting of more or less painful sensations arising from 
the pelvic, abdominal or thoracic region, or by a constrictive 



GENERAL AND FUNCTIONAL DISEASES. 437 

sensation in the throat, or the sensation as of a hard ball rising 
in the throat {glob us hystericus). Sometimes no premonitory- 
symptoms are experienced, the patient suddenly falling to the 
ground, not with the absolute unconsciousness and utter help- 
lessness which characterizes an epileptic seizure, but evidently 
with sufficient lingering discernment to avoid bodily injury 
from the fall. The spasms are clonic oftener than tonic; the 
movements are varied and complicated, frequently showing a 
considerable measure of coordination; the head and arms are 
thrust about in a disorderly, irregular manner, and there may 
be lateral, "to-and-fro" movements of the trunk and hips. 
Sometimes there is persistent rigidity of the body, which in ex- 
ceptional cases may continue for several hours. As the convul- 
sive action ceases, emotional excitement is manifested and con- 
sciousness gradually regained. In some cases the emotional 
excitement is violent, the patient laughing and crying almost 
at the same time. During the attack flatulent distension of 
the abdomen is common; after it has passed, there is usually 
copious emission of limpid, colorless urine. The patient, if 
closely questioned, shows that he remembers much of what has 
taken place. After a severe paroxysm the patient may sink 
into a state of drowsiness which becomes almost a stupor, so 
that he is roused with difficulty; occasionally this terminates 
in a trance or in catalepsy. Exceptionally, particularly in 
children, odd cries are emitted, like the sounds made by animals 
(as the barking and snarling of dogs), and when these are ac- 
companied with attempts to bite, the attacks somewhat re- 
semble hydrophobia ("spurious hydrophobia") from which 
they are, however, easily recognized by the presence of this 
"beast-mimicry," which is characteristic of hysteria. 

Major attacks (hystero-epilepsv) are usually preceded by an 
aura, asfaintness at the stomach, dizziness, sensation of distress 
at the heart, palpitation, or globus hystericus; in other cases the 
patient complains of excessive intestinal flatulency or gives warn- 
ing of an approaching seizure by abnormal behavior or hyster- 
ical excitement. The seizure itself begins by loss of conscious- 
ness, the patient falling to the ground in the half-guarded man- 
ner which has been described. A violent tonic spasm occurs, 
continuing from one to three minutes, the patient lying per- 
fectly rigid, with the arms extended or lying by the side and 



438 DISEASES OF THE NERVOUS SYSTEM. 

the toes pointed outward. The face is bloated and livid, the 
veins turgid, and respiration arrested; the condition is one 
closely resembling epilepsy. The tonic spasm usually continues 
from one to three minutes, and is followed by violent clonic 
convulsions, with frothing at the mouth. Opisthotonos is seen 
in some cases, sometimes so pronounced that the head is curved 
backward far enough to have the upper part of the body rest 
on the face, while the lower portion is supported by the toes. 
Severe clonic spasms may alternate with opisthotonos. Gradu- 
ally relaxation takes place and the patient falls into a condi- 
tion of exhaustion. Succeeding this, there is a stage of emo- 
tional excitement in which the patient assumes an attitude ex- 
pressive of some profound emotion, "posing" with all the effec- 
tiveness of an accomplished actress. She may, for instance, 
remain for some time in a position expressive of religious ec- 
stasy or of penitence; here the so-called "posture of the crucifix" 
is frequently seen. Commonly there is a passing from one 
emotion to another, each manifested by fitting attitude and ex- 
pression; thus fear, anger, penitence, erotism may succeed each 
other and each be eloquently interpreted by posture and gest- 
ure. Hallucinations are frequent here, and may continue for 
some time after all motory disturbances have ceased; they are 
chiefly hallucinations of sight (visions) and hearing, and are 
correlated to the dominating emotion. It is not rare at this 
time to have charges made by the subject against others, 
usually referring to some alleged impropriety of conduct; this 
is the more serious in its possible consequence since the hallu- 
cination upon which these charges rest may persist after com- 
plete recovery from the seizure. Delirium, bordering upon 
mania, has been observed in cases where the neurosis is 
strongly pronounced; its occurrence constitutes a very serious 
feature of the case and renders the prospect of a permanent 
cure more than doubtful. 

The major form of convulsive hysteria is observed much 
oftener in France than in this country. It was made the sub- 
ject of very careful study Iry Charcot and his pupils, who have 
furnished elaborate studies of it under the now freely used term 
hystero-epilepsy. This term is suggested by the resemblance 
of a major attack to an epileptic fit, from which it chiefly 
differs in its longer duration. Taking the hysterical attack as 



GENERAL AND FUNCTIONAL DISEASES. 439 

a whole, it may last several days, the convulsions recurring at 
varying intervals on successive days; such a condition in true 
epilepsy, with no clear-cut periods of recuperation, would be 
highly dangerous to life. 

The attack having passed, the patient may sink into a state 
of narcolepsy, characterized by great drowsiness, or into a 
trance. In the latter, the subject lies in complete repose, with 
pale face, eyes opened or closed, at times scarcely perceptible 
tremors of the eyelids and eyeballs, largely dilated pupils, sen- 
sitive to a powerful light, with rapid and light pulse, and 
usually quiet respiration, sometimes so light that movements 
of the chest-wall can only be discovered by careful watching. 
There may be muscular relaxation or rigidity; if the former, 
spasmodic contractions may take place from time to time. In 
well-pronounced cases there may be anaesthesia of the common 
and of the special senses, and the subject lies insensible to pinch- 
ing, pricking, great heat or cold. Usually the patient can be 
fed without trouble, digestion is good, and bodily nutrition 
excellent. The stools are scanty and passed at long intervals; 
urine is voided involuntarily and in small amounts. In other 
cases artificial feeding becomes necessary, and if the trance is of 
long duration, great emaciation may result. The temperature, 
in protracted cases, eventually becomes subnormal. The dura- 
tion of a trance varies from a few hours to several days; the 
condition resembles death, and in the absence of skilled judg- 
ment may be, and has been, mistaken for it. The awakening is 
sudden or gradual, with reestablishment of circulation and res- 
piration. Sometimes the patient awakens for a brief time only 
to pass into another trance. 

Catalepsy may occur during a state of profound lethargy or, 
exceptionally, as the immediate result of powerful emotional 
excitement. It is characterized by the loss of voluntary move- 
ment of the muscles which remain indefinitely in any position 
in which they are placed. The patient lies in a trance-like con- 
dition, the face either placid or expressive of the emotion felt at 
the time when she passed into this state, with open eyes, regu- 
lar respiration and pulse, normal performance of the functions 
of the body, but with complete anaesthesia of the common and 
special senses. Liquids are taken readily. The duration of 
hysterical catalepsy is very indefinite; the patient may awaken, 



440 DISEASES OF THE NERVOUS SYSTEM. 

take nourishment, and at once relapse; or she may remain in 
the cataleptic state for days, months, and even years. 

The non-convulsive form of Ivysteria possesses features equally 
striking. Hysterical paralysis may come on gradually or sud- 
denly as the result of violent emotional excitement (fright). It 
is essentially a paralysis of the will, the patient having "lost 
the power to will a contraction of the affected muscles," and it 
may resemble an}" form or t} r pe of organic paralysis. Hysteri- 
cal paraplegia is the common form. It is not absolute; the feet 
are usualh' extended and turned inward, there is no wasting of 
muscles, the electrical reactions are normal, there is lessened or 
abolished sensibility, disturbed muscular sense, normal or ab- 
normal knee-jerk, sometimes spurious ankle-clonus. Hysterical 
hemiplegia is rarely complete; it usually affects the left side in 
preference to the right; the leg is involved oftenest, the neck not 
uncommonly, the face never when the case is of hysterical origin; 
sensation on the affected side is lessened or lost. Hysterical 
monoplegia may be facial, crural, or brachial. Hysterical par- 
ah^sis of the vocal cords is not rare; it results in Iwsterical 
aphonia, which exceptionally may become permanent and com- 
plete. Hysterical paratysis of the pharynx and oesophagus is 
infrequent. 

Hysterical contractures are caused by powerful tonic muscu- 
lar contractions; they may occur alone or in connection, chiefly, 
with paralysis and disorders of sensation, especially anaesthesia. 
The}' develop suddenly or slowly, persist indefinitely, and dis- 
appear rapidly. The extremities are oftenest affected, particu- 
larly the arms, which ma}' be flexed at the elbow or wrist, the 
fingers strongly closed upon the thumb, which rests in the palm 
of the hand. If in the leg, the foot is inverted and the toes 
firmly flexed; there is ankle-clonus. Such cases strongly sug- 
gest lateral sclerosis, from which it may be difficult to dis- 
tinguish them. The muscles of the trunk, hip, shoulders, neck, 
rarely the jaws or tongue, may be involved. Phantom-tumors 
in the abdomen, particularly in h^'sterical women at the cli- 
macteric period or after the menopause, suggesting pregnancy, 
are caused by contracture of the abdominal muscles and of the 
diaphragm; these phantom tumors disappear promptly under 
complete anaesthesia. 

Clonic spasms are frequent. They are characterized by a 



GENERAL AND FUNCTIONAL DISEASES. 441 

rhythmic movement which is suggestive of chorea. They may 
involve the arms, giving rise to rhythmic flexion and exten- 
sion, more rarely to pronation and supination, or the sterno- 
cleido-mastoid, or the muscles of the jaws, or the rotary mus- 
cles of the head, or the psoas muscles of the leg, lifting the leg 
in rhythmic manner from six to ten times in the minute, or the 
muscles of the trunk, causing the patient to bend forward as 
though making a series of bows (Salaam convulsions), or the 
muscles of the back, forcing backward movements. Other rare 
forms are described. 

Hysterical tremors usually affect the hands and arms, more 
rarely the head and legs. They may occur alone or in connec- 
tion with paralysis and contractures. 

Disorders of sensation belong to the most important charac- 
teristic symptoms of hysteria which are comprised under the 
general term "hysterical stigmata." Hysterical anaesthesia is 
common. It may affect the skin and partake of the nature of 
analgesia, which is essentially a manifestation of hysteria. 
Such patients may run a needle deeply through a fold of skin 
without experiencing pain. Anaesthesia may be general, but 
usually it is localized and the affected area is bounded by 
normally sensitive skin; again, spots of hyperesthesia may 
occur within an anaesthetic area, the hypersensitive spots 
(region of groin, ovary, dorsal, lumbar, lower cervical region) 
being superficial or discovered only on deep pressure. Anaes- 
thesia usually affects one-half of the body (hemianaesthesia), 
and the dividing line between the normal and affected half is 
distinctly defined. The affected surface usually is pale and may 
not bleed from the infliction of slight wounds such as usually 
give rise to bleeding (ischasmia); this feature was distinctive of 
several epidemics of hysteria during the middle ages and was 
thought of miraculous origin. Changes in the sensibility to 
temperature, pressure, or other external influences, may or may 
not be present; thermo-anaesthesia is common. In many cases 
the deeper subcutaneous tissues are involved, with resulting 
loss of muscular sense. 

The organs of special sense are often affected, especially the 
eyes. Indistinct vision is a frequent symptom of hysteria, limi- 
tation of the visual field arising from anaesthesia of the peri- 
pheral portions of the retina. Loss of the color sense (hysteri- 



442 DISEASES OF THE NERVOUS SYSTEM. 

cal achromatopsia) is also occasionally seen, the perception of 
certain colors disappearing gradually and in the order given, 
i. e., violet, green, blue, yellow; the intermediate tints also fade 
awa}', and finally all objects appear of a sepia tint. There may 
be loss of hearing, sense, smell, and taste, though not complete. 

Duchenne pointed out that in these cases there may be a cat- 
aleptic state when the eyes are closed; that is, inability to move 
amusck — say, the muscles of the arm — when the eyes are closed, 
although perfectly able to do so when the eyes are open; the 
explanation of this phenomen is probably psychical. 

Hysterical hyperesthesia is one of the most common symp- 
toms. It may occur in one definite spot or in areas of varying 
extent. Its distribution is irregular. Great sensitiveness and 
pain are characteristic. Here belongs clavus hystericus, an in- 
tense pain usually over the sagittal suture, sometimes in the 
occiput, the patient complaining of a sensation as though a nail 
were being driven into the head; other illustrations are: excess- 
ive tenderness of the female genitals, with loss of sexual desire 
and vaginismus; swelling and painful tenderness of the female 
breasts, with sharp neuralgic pains which frequently extend 
down the arm; swelling and severe pain affecting the larger 
joints; pain in the back, with great sensitiveness, limited to 
certain spinous processes; or diffuse, sharp pains in the abdo- 
men, in certain spots, resembling the pains of gastralgia, gastric 
ulcer, peritonitis or, more rarely, appendicitis. The special 
senses may be affected. Photophobia is quite common and 
often very persistent. Hearing, taste and smell frequently are 
very acute. 

Cardiac irritability occurs in many cases and is expressed in 
violent, distressing palpitation from even slight emotional ex- 
citement. There may be with it severe pain, shooting down 
the arm, like that of angina pectoris; according to H. C. Wood, 
this is oftenest seen in the hysteria of young men. Flushings, 
with hot spells and often profuse sweating, are observed chiefly 
in women at the climacteric period. Vicarious menstruation 
(bleeding from nose or stomach) is observed in young girls. 
Stigmata or haemorrhages in the skin have undoubtedly 
occurred in rare cases, though here, as in instances of exceed- 
ingly high bodily temperature, a strong suspicion of fraud may 
always be entertained. 



GENERAL AND FUNCTIONAL DISEASES. 443 

Respiration is often very rapid, without marked increase in 
the rate of the pulse. Dyspnoea is frequent. A "catching" of 
the breath at every fourth or fifth inspiration occurs in a great 
number of cases. Aphonia from involvement of the muscles of 
the larynx has been mentioned. There may be violent laryn- 
geal spasms, simulating laryngismus stridulus. The sounds 
which resemble those produced by animals, as barking or 
mewing (beast-mimicry), result from violent inspiratory or ex- 
piratory efforts. There may be persistent hiccoughing, often 
continuing for a long time. The so-called hysterical cough is a 
hoarse, croaking, exceedingly unpleasant laryngeal cough, fre- 
quent in young girls; cynobex hebetica is a term used by Sir 
Andrew Clark to describe a similar cough in neurotic young 
boys, lasting about a minute and recurring often. 

The digestive system is nearly always disturbed. There is 
more or less gastric and intestinal flatulency, with a striking 
tendency to persistent and painless regurgitation of food, 
which may continue for years without any apparent ill results. 
Hysterical spasms of the oesophagus may render swallowing 
difficult and cause rejection of the food before it reaches the 
stomach. Hysterical vomiting also is frequent and persistent, 
and may eventually result in anorexia nervosa, sl condition in 
which absolute loathing of food exists, the patient uncondi- 
tionally refusing to eat and experiencing severe suffering on the 
approach of food. This condition is seen in the so-called "fast- 
ing girls" who occasionally attract public attention. Extreme 
emaciation and weakness develop in due time, with death from 
exhaustion, unless the patient can be kept alive by forced and 
artificial feeding. Recovery of these cases may occur from a 
change of surroundings or under the Weir Mitchell treatment. 
Sometimes hysterical vomiting is followed or accompanied by 
intestinal peristalsis, resulting in vomiting of fascal matter. 

Intestinal flatulency is often severe; it may be associated 
with spasmodic contraction of the abominal muscles, giving 
rise to strange noises which to sensitive people are a source of 
great affliction ( Kiissmaul's ' 'peristaltic unrest' ' ) . Constipation 
is the rule, and may be exceedingly stubborn from loss of mus- 
cular power, an immense amount of faecal matter accumulating 
in some extreme cases where the bowel had not been emptied 
for two, or more, weeks. Diarrhoea is not so frequent, but 



444 DISEASES OF THE NERVOUS SYSTEM. 

may be very intractable, evacuations occurring whenever food 
has been taken. In other cases, occurring less often, the rec- 
tum may be very irritable, and scybala may be forcibh' ejected 
several times during the da\\ Pain in the rectum, as from 
fissure, and spasms of the sphincter ani have been noted. 

The temperature usually is normal. Fever, however, is often 
present. It may appear without other disturbances, and is then 
not easily recognized as hysterical; or it may be associated 
with various manifestations and deceptive local disturbances; 
again, it may run a course of several weeks, with disturbances 
of nutrition, resembling typhoid fever or assuming the type of 
an intermittent. Cases of slight feverish excitement, with 
cough and bloody expectoration, have been observed. In- 
stances are reported of remarkable hyperpyrexia, the tempera- 
ture reaching 120°, or more. Fraud has been proved in some 
of these cases, while others, though as yet inexplainable, must 
be accepted as authenticated. 

Hysterical joint affections are a perplexing feature of hysteria. 
The joints usually affected are the knee and the hip. The joint 
is very sensitive, swollen, and fixed; it cannot be touched or 
moved without much suffering. Occasionally there is wasting 
of the soft tissues about the articulation, increasing the ap- 
pearance of swelling in the j oint itself. The surface temperature 
is usually above normal. It is probable that the local trouble 
is due to inflammatory action outside the capsule of the joint, 
brought on by some slight inju^. 

Sweating is frequent, and sometimes the perspiration is 
slightly tinged with blood (haematidrosis) . The urine is gener- 
ally light-colored, limpid and copious, especially during recov- 
ery from a violent paroxysm. Sometimes anuria persists for a 
long time and seriously interferes with the excretion of the 
urinary solids. 

The mental symptoms are those of a perverted moral nature 
with a weakened will. The patient thinks only of self and of 
making "self the centre of the world in which he, or she, 
moves. To absorb the attention of others, infinite pains will 
be taken. She will exert herself to the utmost to be agreeable 
or fascinating; she will exaggerate slight ailments or troubles 
to command general sympathy; if neither ailments nor troubles 
exist, the}- are manufactured to order, for the hysterical patient 



GENERAL AND FUNCTIONAL DISEASES. 445 

easily learns to resort to deceit and falsehood. This perversion 
of the moral sphere strongly partakes of the elements of in- 
sanity, and for practical purposes must be so considered. 

Prognosis. — With the exception of rare cases of severe hyster- 
ical vomiting, no danger whatever exists to life. The pros- 
pect of a permanent recovery is best when the patient is young, 
and since almost one-half of all the cases occur between ten and 
twenty years of age, there is in the majority of them reason- 
able hope of a permanent cure. The outlook is not good in 
severe cases of hystero-epilepsy or in other severe forms of hys- 
teria which occur in adult life, usually from trauma. 

Diagnosis. — In the majority of cases it is not difficult to rec- 
ognize hysteria. A careful inquiry into the history of the patient, 
including the possible existence of a neurotic tendency, pre- 
vious manifestations of an hysterical character, and the mental 
condition of the patient, must first of all be made. The presence 
of globus hystericus, emotional excitement, crying and sobbing, 
and, in case of convulsions, the absence of injury from falling, 
the purposive movements during the spasms and the prolonged 
duration of the attack itself, are practically sufficient to estab- 
lish the diagnosis. The variable, shifting character and the 
association -with anaesthesia establish the identity of hysteri- 
cal paralysis. In hysterical contractures the character of the 
deformity may be suspected from the presence of other manifes- 
tations of hysteria; they disappear under complete anaesthesia; 
the reare areas of anaesthesia; the visual field is retracted. — In hys- 
terical affections of the joints a general hysterical condition is 
likely to exist; the muscular rigidity may often be overcome by 
moderate force employed while the attention of the patient is 
diverted to some other matter of interest; the contracture 
yields during sleep and under slight anaesthesia; the atrophied 
muscles respond normally to electric stimulation (faradic cur- 
rent). Care must be had not to mistake hysterical spastic par- 
aplegia for lateral sclerosis. 

Treatment. — The entire subject of prophylaxis is embraced in 
a sensible, judicious bringing-up of children who have inherited 
a neurotic tendency. Both body and mind must be properly 
trained. An abundance of out-door life, with all the play or 
exercise the child can bear without being taxed, long hours of 
sleep, plain and nourishing diet, warm and sensible clothing, 



446 DISEASES OF THE NERVOUS SYSTEM. 

and regular hours of study, at no time sufficient to become 
burdensome, yet enough to occupy the mind and insure intel- 
lectual growth, are of supreme importance. The management 
should be wise; there must be no "babying" of any kind; 
prompt obedience to parental authority must be exacted, and 
pains taken to develop self-control and a due sense of responsi- 
bility in the relations of child-life. Such a course will be the 
more effective if the child is not allowed to suspect that it is the 
object of special solicitude or anxiet}'. Unfortunately, parents 
of such children do not always possess the ability or good 
sense to carry out such a plan. 

The treatment of hysteria itself is very largely of a moral 
character, and success depends chiefly upon the clearsighted- 
ness and tact of the medical man. He must observe and duly 
weigh everything concerning the patient and her surroundings. 
He must alike avoid unnecessary brusqueness of manner and 
an appearance of deep sympathy; if too brusque, he may give 
just cause of offense; if too kindly and sympathetic, he may 
find it difficult to keep the patient at a proper distance from 
himself. He must not scold and censure that which is in reality 
the result of sickness, neither can he admit that the patient, by 
the exercise of will, may not control at least incipient attacks 
of hysteria. He must develop in the patient unselfishness and 
self-control, yet he is rarely in a position to make her surround- 
ings such as will aid his efforts in this direction. Above all 
things, he must succeed in teaching the patient that she is to 
obey implicitly and to the letter. 

In a general way the treatment is largely that of neuras- 
thenia. The patient must be relieved of any organic or other 
affection which aggravates her condition. Electricity, cold 
sponge-baths, cold douches, massage and sea-bathing are 
helpful when judiciously employed. If at all possible, the pa- 
tient should be removed from home, beyond the reach of 
anxious and injudicious friends, to some quiet mountain resort 
or to the sea-side, and there kept under the watchful care of an 
experienced, tactful nurse who is able and willing to be at- 
tendant, guardian and companion. Places of an}' sort where 
invalids congregate are to be religiously avoided, since the dis- 
cussion of their various affections will be}'ond doubt arouse in 
the hysterical patient a determination to outshine them all, 



GENERAL AND FUNCTIONAL DISEASES. 447 

thus at once defeating all hope of receiving benefit from a 
change of surroundings. In severe cases the perfect isolation 
from all friends and acquaintances, including even letters from 
them, the absolute rest, systematic and abundant feeding, with 
daily massage and electricity, which constitute the Weir 
Mitchell treatment, promise relief which may not be obtained 
in any other manner, especially in cases of thin and badly 
nourished persons. 

When in convulsions, it is well to let the patient alone. Exer- 
tions on part of the attendants, especially the physician, are 
what the patient demands, and to insure them she will do every- 
thing in her power to increase the severity of the attack and the 
incidental display of suffering. If unsuccessful, the patient will 
be disgusted and not think it worth her while to exert herself. 
At times it is well to use a cold douche or cold shower-bath, so 
as to arouse her will and gain control over the muscles; some- 
times violent vomiting, produced by lobelia or any other 
emetic, preferably the hypodermic injection of apomorphia 
(gr. 2V to jiy), will cut short the spasm and prevent its recur- 
rence, not by any specific action upon the hysterical condition, 
but simply by arousing the will power of the subject. Medical 
literature abounds in cases of hysteria which for many years 
had resisted all attempts at a cure, and yet made an instanta- 
neous and permanent recovery from the sudden occurrence of 
an accidental or manufactured emergency; here belong cases of 
long-standing paralysis suddenly cured by an alarm of fire in 
the house. 

Hysterical Paralysis. — The subject must be made to regain 
the use of the palsied limb by exercise. This may be accom- 
plished by first placing her on her feet, then making her walk 
slowly, firmly supported on each side, increasing the exercise as 
she is able to bear. Perseverance usually brings about a cure 
by this means alone. Massage and the electric current are also 
useful. Paralysis Of the vocal cords demands the same treat- 
ment, electricity being applied within the larynx or externally. 

Contractures require energetic passive motion, secured by 
massage and faradism, and regular exercise in voluntary move- 
ments. Hypnotism has been successfully used. 

Anaesthesia calls for the use of the faradic wire-brush. Pseudo- 
hysterical angina pectoris is not often severe enough to require 



448 DISEASES OF THE NERVOUS SYSTEM. 

special treatment; nitro-glycerine, amyl nitrite, digitalis, 
spigelia and similar remedies may be exhibited to advantage. 
Painful spots in the back ("irritated spine") are frequentry re- 
lieved by a belladonna plaster. Severe hysterical vomiting may 
necessitate artificial feeding; if so, the nasal-oesophageal tube is 
preferred. In hysterical affections of the eves or ears it is ad- 
vised not to humor the patient by allowing the use of smoked 
glasses or living in darkened rooms, or by the exclusion of 
common sounds. — If catheterization is necessary, the operation, 
upon a woman, should be performed by a woman nurse. 

Treatment bj r "suggestion" has found many advocates. Its 
success depends upon the proper relation of the patient to the 
pltysician, i. e., one of perfect confidence and readiness to co- 
operate. It is suggested that mock surgical operations, the use 
of offensive drugs, and similar measures, frequently prove use- 
ful because they create a strong impression upon the mind of 
the subject. 

Therapeutics. — It is still an open question whether, or not, 
permanent relief in this condition may be afforded by the use of 
internally administered remedies; that they are often helpful, 
especialh^ in times of great emotional excitement, cannot be 
denied by any who have given them an intelligent trial. — 
Ignatia is by all means the most frequently indicated and most 
reliable remedy. Its mental symptoms are particularly im- 
portant. It acts best when there is intense emotional excite- 
ment, globus hystericus, and "sinking" sensation at the epi- 
gastrium, with characteristic headaches (clavus). The patient 
is full of grief, weeps, sighs, sits by herself, nursing her sorrows. 
It has copious flow of urine during and after hysterical seizures. 
— Asafcetida is an important remedy. The presence of gastric 
flatulency, causing palpitation or excited action of the heart, 
with flushing of the face, is a reliable indication. Hale is correct 
in stating that it is especially useful in large, fleshy, emotional, 
excitable and passionate women, and that it must be continued 
for a long time to do its best work. It should be used in the 
low attenuations. — Moschus. The symptoms are striking. 
The patient faints upon every occasion, from the slightest 
cause, and faints often, especially in a warm room. Spasmodic 
constriction of the larynx and chest, so severe that suffocation 
seems imminent. Globus hystericus. Great dyspnoea, asso- 



GENERAL AND FUNCTIONAL DISEASES. 449 

ciated with pain about the heart, like angina, and violent pal- 
pitation of the heart. Tremulous nervousness. Copious, pale 
urine. — Aurum. Great, even uncontrollable, sexual excitement, 
bordering upon mania, often with heat, swelling and great 
itching of the pudenda and sensitiveness of the vagina, accom- 
panied with cardiac irritability and palpitation. Her nights 
are rendered unbearable by intensely lascivious dreams. She 
becomes unstrung, hysterical, threatens to kill herself, but is 
too afraid of dying to make serious attempts at suicide. Heat 
on the top of the head. — Aurum muriaticum natronatum. 
''Hysterical spasms, with unconsciousness for several hours, 
beginning with coldness starting from abdomen, sometimes 
with pulsation in occiput, with inflamed uterus filling the 
entire pelvis, interferring -with the action of the bowels and 
bladder, entirely cured." T. F. Allen. — Cocculus, especially at 
the menstrual period, with numbness and weakness of the ex- 
tremities. Nausea and vomiting exceedingly troublesome from 
their persistence; extreme aversion to food; hysterical dyspnoea. 
— Nux moschata. Hysteria with frequent fainting from slight 
causes, with enormous bloating of the bowels, vaginal flatu- 
lency, fluttering of the heart -with faintness. Tendency to a 
comatose state. Dryness and coldness of the skin. — Pulsa- 
tilla. In women who weep whenever anything ails them. 
Characteristic catarrhal, gastric and menstrual derangements. 
Neuralgia, with chilliness. — Platina. Hysterical alternations 
of laughing and weeping; constriction of the oesophagus; 
globus hystericus; alternations of anaesthesia and hyperes- 
thesia. Melancholia, with notions of grandeur; religious mel- 
ancholia with palpitation of the heart and great dread of 
death. Hysterical gastralgia. Sexual melancholia. Satyria- 
sis. Nymphomania with extreme sensitiveness of the external 
genitalia, sometimes with numbness. Characteristic uterine 
disorders. Extreme nervous excitability; sleeplessness. — Tar- 
ENTUla. Violent alternations of moods, especially with sudden, 
stealthy and destructive impulses. Hystero-epilepsy, with wild 
shrieks. Hysteria, with constant movement of the extremities, 
especially of the hands. — T. F. Allen doubts the reliability of 
this remedy in hysteria. I have no experience with it. Among 
other reported cures the late W. H. Holcombe relates the follow- 
ing case: The attacks commenced by spells of yawning and 
29 



450 DISEASES OF THE NERVOUS SYSTEM. 

irregular breathing; these were followed by muscular contrac- 
tions of even*- sort; first fixed look, lasting for several minutes, 
followed by wild shrieks, and this followed by continued coma; 
the whole scene varied from time to time by In^sterical par- 
oxysms of laughing and crying. I have never witnessed more 
astounding and complicated h3 T sterical phenomena in my life. 
Epilepsy, catalepsy, chorea, tetanus, Ivydrophobia, apoplexy, 
ecstasy, somnambulism, spinal irritation and ordinary hys- 
teria, all seemed to have a hand in producing the constantly 
shifting panorama of S3^mptoms. The patient, who at the end 
of a month's treatment was worse instead of better, was cured 
in two days by Tarentula. — Valeriana. Globus hystericus; 
feeling as though something warm were rising from the stom- 
ach into the throat. Great fear of being left alone, especially 
in the dark. 

When convulsions are violent, consult Belladonna, Cicuta, 
Hyoscyamus, Stramonium. The expressed juice of Passiflora 
incarnata, in physiological doses, is said to have a very sooth- 
ing effect when there is great restlessness and sleeplessness. See 
also remedies under Neurasthenia. 

VERTIGO. 

A sensation or appearance of movement, involving a real or 
seeming defect in the equilibrium of the body, with more or less 
disturbance of consciousness and, often, distinct perversion of 
the special senses. If subjective, the subject appears to himself 
to move; if objective, external objects seem to move. The 
vertiginous state consists of attacks of vertigo which follow 
each other rapidly. 

Organic or arteriosclerotic vertigo occurs in connection with 
cerebral disease characterized by impairment of nutrition from 
arterio-sclerosis of the vessels of the brain. Cardiac vertigo 
depends upon fatt} r , or other, degeneration of the heart, with 
failing power, excited by physical exertion or mental excite- 
ment; it is also a feature of the distress caused in some persons 
by the greatly rarified atmosphere of a high elevation. Epilep- 
tic vertigo is a symptom of idiopathic epilepsy. Neurasthenic, 
hysterical or neurotic vertigo arises from exhaustion or irrita- 
tion of the nerve centres, as seen in neurotic conditions; it often 
is excited from sudden, severe peripheral sense-irritation, as a 



GENERAL AND FUNCTIONAL DISEASES. 451 

sudden and brilliant flash of light. Ocular or ophthalmic ver- 
tigo is usually a result of severe disorder in the ocular motory 
apparatus. It is often accompanied with a sensation of falling 
backward, and there maybe severe pain in the back of the neck. 
Irritation of the special sense from waltzing, swinging or rapid 
whirling about, the passing of rapidly moving objects (cars), 
possibly sea-sickness, causes a form of ophthalmic vertigo with 
nausea, vomiting, great prostration and heart-failure. Aural 
vertigo is a conspicuous feature of Meniere's disease (sudden 
congestion of, or apoplexy into, the semi-lunar canals) and of 
Yoltolini's disease (purulent labyrinthic otitis); also of affec- 
tions of, and mechanical interference with, the Eustachian 
tubes. The terms "gastric," "bilious," "intestinal" vertigo 
are self-explanatory. Laryngeal vertigo follows a sharp, spas- 
modic cough, with laryngeal hypersensitiveness. Toxasmic 
vertigo arises from alcoholic, uraemic, lithaemic, and other, 
poisoning; bilious vertigo may belong here. The essential 
vertigo of Gowers is caused by some unknown morbid state. 

The treatment of vertigo is addressed to its primary cause. 
Thus, in vertigo arising from gastric, intestinal or bilious dis- 
turbances, Nux vom., Bismuth, Asa fgetida, Bryonia, Calcarea 
carbon., Chelidonium, China, Colchicum, Collinsonia, 
^Esculus, Hydrastis, Mercurpjs, Podophyllum, Pulsa- 
tilla, Sabadilla, Sulphur, and others, must be carefully 
studied. — Aural vertigo usually demands Gelsemium, Causti- 
cum, Salicylate of soda, Aurum. — Organic or cerebral vertigo 
suggests Causticum, Zincum, Argentum nitric, Anacardium, 
Plumbum, Cuprum, Opium, Tabacum, and others; if charac- 
terized by congestion, Belladonna, Glonoin, Stramonium, 
Hyoscyamus, Kali bromatum. If due to anaemia: Ferrum, 
China, Phosphorus, etc. — In neurasthenia and other neurotic 
states: Gelsemium, Lachesis, Coca, Cimicifuga, Cocculus, 
Ignatia, Kali bromatum, Moschus, Nux moschata, Platina, 
Coffea, Ambergris, Theridion— In feeble persons of advanced 
years, Conium, Aurum and Alumina are to be consulted. In 
short, routine prescribing is a waste of time; nothing will 
answer the purpose save an exhaustive examination of the 
materia medica and of the aetiology of each case. 



452 DISEASES OF THE NERVOUS SYSTEM. 



EPILEPSY. 

A nervous affection of unknown pathology, characterized by- 
attacks of unconsciousness, occurring at long or short inter- 
vals, with or without convulsions. If accompanied with gen- 
eral convulsions, they are described as Grand mal, while the 
term Petit mal is applied to the more transient paroxysms in 
which no convulsions are seen. At times the spasms are 
localized, and there may, or may not, be loss of consciousness; 
this form is described under the term Jacksonian or Cortical 
Epilepsy. 

j*Etiology. — Heredity is beyond doubt a most important 
factor, if b} r this we understand an inherited neurotic tendency, 
expressing itself in the parents by a general predisposition to 
affections of the nervous system, as insanity, hysteria, etc. 
Direct inheritance, or the transmission of epileps}- from an epi- 
leptic parent to the child, is comparatively infrequent. What- 
ever in a parent weakens vitality and the tone of the nervous 
system may in the child cause a predisposition to epilepsy, as 
to other nervous affections; hence, alcoholism, sexual, and 
other, excesses in a parent are in a limited sense to be considered 
here. Steady hard drinkers are often epileptics, and syphilitic 
brain lesions may result in epilepsy. Among the exciting 
causes, violent emotions, especially fright, have been considered 
common factors; it must, however, be admitted that their im- 
portance has probably been overestimated; they would not 
lead to such serious results were not the tendency to epilepsy 
so strong that it requires only a trifling cause to bring on the 
explosion. The same applies to infectious fevers. Epilepsy 
has also occurred during the passage of gall-stones, during the 
removal of pleuritic fluid, from imprudence in eating and 
other causes which appear trifling. It was thought for a time 
that cases had been traced to eye-strain, and that correction 
of the evil had resulted in cure, but this opinion is no longer 
entertained. "Traumatic" epilepsy results from a fall, blow, 
cut or similar injury to the head. Since here an anatomical 
basis always exists (cortex), even though usually not exten- 
sive, such cases do not constitute true epilepsy. Again, the 
affection may be reflex in character, as in the case of a splinter 
which is retained and exerts pressure upon a peripheral nerve 



GENERAL AND FUNCTIONAL DISEASES. 453 

trunk, or a cicatrix pinching a nerve, or the irritation arising 
from dentition, from some foreign body in the ear or nose, or 
from a tightly adhering prepuce. Removal of the offending 
body may be followed by a cure. Such cases, however, are 
more rare than is generally supposed. — Epilepsy occurs in both 
sexes; the many tables published show no decided preference 
for either sex. It usually sets in during the first two decades 
of life. Of 1450 cases collected by Gowers, 422 cases occurred 
before the tenth year, and three-fourths of the entire series be- 
fore the twentieth year; it rarely begins after the thirtieth 
year. 

An interesting feature of this affection is the establishment of 
the "epileptic habit" in cases of reflex origin; the cause may be 
removed, but the seizures continue. 

Symptoms. — Grand Mai. — In nearly every instance a major 
seizure is preceded by a warning {aura) consisting of some ab- 
normal, odd sensation in some part of the body; of these a very 
large variety has been recorded, but whatever its character 
may be, it is nearly always the same in the same person. The 
aura may precede from one finger, or one hand, or a foot, ex- 
tending from the periphery to the centre, toward the head; 
when it reaches the head, the patient falls. In other cases there 
may be gastric distress which the patient cannot describe, com- 
monly with a feeling as though something were rising from the 
stomach, or it may be a sensation of tightness or of choking 
in the throat, or a heart-burn, oracolicky pain in the abdomen. 
Frequently the aura refers to the special senses, oftenest the 
eyes; thus there are seen flashes of light, or a display of colors, 
red appearing first; or objects about the room may suddenly 
change in size, or there may be loss of vision; if referring to the 
ears, sounds are heard, voices, music, possibly the sound of 
hissing steam; rarely unpleasant odors or tastes constitute the 
warning. Sometimes there is a feeling of a breath of air or a 
draft striking him. Again the aura may be psychical, as a 
state of sudden excitement, apprehension, fear .or mental ab- 
straction; or, quite rarely, it is intellectual, consisting of some 
thought or idea which always recurs just before an epileptic 
spasm. Or some motor phenomena may regularly take place 
at this time; the patient may, for instance, all at once start on 
a run, or he may suddenly begin whirling round and round 
with astonishing swiftness. 



454 DISEASES OF THE NERVOUS SYSTEM. 

Exceptionally an aura may be distinct^ felt, }^et no spasm 
follow; sometimes sufficient time elapses between the aura and 
the convulsion to have the patient guard against possible in- 
jury from falling or even to warrant an attempt to avert the 
seizure. 

The onset of the seizure often is marked by a loud cry (epilep- 
tic cry), which results from forcing air through the narrowed 
glottis; in hysteria a similar noise may be made, but, unlike the 
cry of epileps}-, it usually is repeated. When the cry is made, 
the patient falls unconscious, as though shot, without attempt- 
ing to protect himself against injury, and often receiving a 
serious hurt, of which at the time he is insensible. 

A violent tonic spasm constitutes the first stage of the seizure 
proper. The patient lies in a state of perfect rigidity, with ex- 
tended legs, the head drawn back or toward one side, prefer- 
ably the right, the head and neck twisted to one side, and the 
jaws fixed. The arms usually are flexed at the elbows, the 
hands at the wrists, and the fingers either tightly closed upon 
the thumb in the palm of the hand or fixed in a position as 
though grasping a pen, with the thumb resting against the 
first finger. The knees and hip-joints may be flexed or the legs 
and feet rigidly extended. The thoracic and abdominal muscles 
are fixed; hence there is impeded or arrested respiration, with 
cyanosis; the face, which at the beginning was pallid, quickly 
assumes a dusky, livid hue; the facial muscles are convulsed, 
especially on the side towards which the head is drawn. The 
duration of the tonic spasm lasts from a few seconds to a 
minute, or more. 

The clonic stage begins with lessening of the tonic rigidity, 
followed by tremors and vibratory muscular movements which 
rapidly grow stronger and, developing distinct intermissions, 
culminate in violent general clonic spasms. The movements 
are severe, shock-like; the arms and legs are thrown about 
heedless of possible injury; the head is pounded upon the floor; 
the muscles of the face are powerfully agitated; the eyes roll 
spasmodically, and the lids are opened and closed convulsively; 
the jaws close with great force and, in case the tongue pro- 
trudes, inflict upon it severe injun^; frequently the tongue is 
thrust forward and back, and may thus be caught between the 
teeth. Frotlvy, often bloody, saliva escapes from the mouth, 



GENERAL AND FUNCTIONAL DISEASES. 455 

and there may be involuntary discharge of faeces, urine or, in 
men, seminal fluid. 

Respiration is slow, irregular, noisy, and in some cases seems 
almost arrested. The pupil of the eye during the height of the 
paroxysm is immovable and dilated, and frequently at this 
time insensible to touch; return of the pupil to a normal condi- 
tion may be considered a sign that the spasm is yielding. The 
pulse at first is feeble, later it becomes rapid and full. The 
bodily temperature is nearly alw ays elevated. The convulsions 
usually are stronger on one side of the body than on the other. 
This stage lasts from one to two, or more, minutes. 

The last stage, that of coma, is initiated by a gradual cessa- 
tion of the spasms and general muscular relaxation. Respira- 
tion is reestablished; it is at first noisy and stertorous. The 
face loses its lividity, but is flushed for some time. The patient 
remains in a state of profound unconsciousness, gradually as- 
suming the character of a heavy sleep which may continue for 
hours. In other cases the patient is easily roused, and not in- 
frequently, even though the spasm may have been quite severe, 
he awakens of his own accord after a few minutes of rest. 
There is almost always some degree of mental confusion, heavy 
and stupid headache, and some muscular soreness. 

After an attack, and for some little time, the knee-jerk usually 
is absent; sometimes it is exaggerated; ankle clonus is present 
in the greater number of cases. The urine is increased and not 
infrequently contains albumin. There may also be paresis of 
one side or of one limb, but it is transient and of short duration. 

Should the spasms be repeated, following each other in rapid 
succession, the patient failing to regain consciousness, the con- 
dition (status epilepticus) is one of great danger. In such cases 
there is a decided rise of temperature (105° to 107°), and death 
may occur from exhaustion. 

Petit Mai consists of sudden periods of unconsciousness, 
nearly always coming on without a distinct aura; they may be 
associated -with faintness and dizziness. The patient suddenly 
stops in whatever occupation he may be engaged, remains 
motionless for a few moments, with pallid face and fixed eyes, 
dropping any thing he happens to hold in the hand; in a moment 
or two, usually with a somewhat dazed look, he proceeds with 
his occupation, possibly eating or playing cards or chatting, as 



456 DISEASES OF THE NERVOUS SYSTEM. 

though nothing had happened. Such an attack may occur on 
the street, the patient continuing to walk and, upon recover- 
ing consciousness, finding himself lost. In this state he may 
enter upon long journeys or commit other acts which are inex- 
plainable. In many cases the patient appears vaguery con- 
scious that "something is wrong;" frequently incoherency is 
shown by the automatic performance of some act which is 
wholly out of place; thus it is not unusual for women to begin 
undressing. Exceptionally some grave impropriety or wrong 
may be thus committed, causing serious distress to the patient 
and his friends. 

It is the common experience that these minor seizures gradu- 
ally grow worse, eventually terminating in grand mal, when 
the two forms alternate. 

Various and manifold deviations occur from the types de- 
scribed; cases seen in practice present a range from the slightest, 
scarceh- perceptible, seizure to attacks of terrible intensity. 

Often attacks occur only in the night, and in that case they 
may for a long time exist unsuspected, the patient after the 
seizure passing into a quiet, refreshing sleep. The conditions 
which should arouse suspicion are unaccountable weariness and 
muscular soreness in the morning, laceration of the tongue, and 
possibly wetting of the bed during sleep, which cannot be other- 
wise accounted for. 

Again, there is a rather rare class of cases in which there are 
strongly pronounced circulator disturbances, and it is difficult 
to decide whether these or the nervous symptoms are the 
primary affection. This has been called cardiac epilepsy, of 
which two forms are distinguished, the syncopal and the con- 
gestive. The SA-ncopal form is characterized by an exceedingly 
low pulse, perhaps ten beats per minute, and subnormal tem- 
perature. The attack maybe ushered in by an aura, sometimes 
a feeling of intense coldness. The convulsions are not violent. 
The congestive form presents symptoms of extremely excited 
circulatory disturbance, with violent congestion to head, face, 
and conjunctiva, and with free epistaxis. Convulsions here are 
violent. In some cases no convulsions occur, but the patient 
suddenly begins to walk forward and backward, or to run 
rapidly in a circle, or to spin round and round with astonish- 
ing rapidity, or possibly rush out of the house, covering a long 



GENERAL AND FUNCTIONAL DISEASES. 457 

distance, evidently acting upon an impulse which he cannot 
control. This is epilepsia precursiva, a form which is almost 
limited to childhood, eventually assumiug the usual classical 
form. It is closely associated with moral insanity. 

Samt has described certain psychical disturbances which 
take the place of convulsive seizures and which he classes under 
the name of "epileptic equivalents;" these have been extensively 
studied by others, and embrace sensory, sensorial, and psychi- 
cal symptoms appearing in paroxysms and followed by ex- 
haustion. To these belong attacks of angina pectoris, asthma, 
spasms of the glottis, neuralgia of the viscera, migraine, and 
mental disturbances characterized by vacuity and violent, irre- 
sistible impulses in the direction of some outrageous, indecent 
act or the commission of some crime. 

While epilepsy has existed in some persons of distinguished 
ability, even these have shown the disturbing influence of this 
affection upon the emotional life, engendering an emotional 
irritability which renders the subject liable to be easily moved 
to hilarity or anger and violence. If this tendency is strongly 
pronounced, it may terminate in epileptic mania, characterized 
by intense excitement, delirium, and hallucinations and delu- 
sions which conform to the type of the emotional storm. The 
condition may be one of absolute frenzy in which the subject 
has no control of himself, is violent in the extreme, and may 
commit homicide or suicide. Such seizures may last a short 
time or for days. Upon recovery the patient has no recollec- 
tion of anything that has taken place and is always extremely 
exhausted. If the attack was unusually short and light, he 
may vaguely remember what occurred. Such cases are of im- 
portance from a medico-legal aspect. If there has been com- 
mitted a crime of more than usual atrociousness, without mo- 
tive, useless and brutal in every sense, and the criminal appears 
to have no recollection of it, the previous history of the ac- 
cused should be carefully examined in reference to possible 
proof of epilepsy. Attacks of mania may recur at irregular in- 
tervals after periods of perfect mental soundness; these recur- 
rences are in every sense repetitions of previous attacks. 

Progressive mental enfeeblement and even dementia may oc- 
cur; in cases which do not reach this stage, mental dullness and 
failure of memory are common. Imbecility and idiocy are con- 
nected with organic changes in the brain. 



458 DISEASES OF THE NERVOUS SYSTEM. 

The frequency of the paroxysm varies very much. They may 
occur at intervals of many 3'ears, or several may take place in 
the twenty-four hours; in the average case there are recurrences 
ever}- two to four weeks. Certain external influences materially 
affect the frequency of the attack. Alcoholic excesses, great 
sexual excitement, violent mental emotions or effort, "over- 
doing," and imprudence in diet will almost always increase the 
frequency of the attacks, while an abstemious and orderly way 
of living has a beneficial effect. Hirt states that the occurrence 
of copious bleeding from the nose increases the interval between 
paroxysms, and that, in case there is a motor aura, the applica- 
tion of a tight strap or bandage to the finger or hand from 
which it precedes may avert a seizure. During pregnancy 
epileptic women sometimes are comparatively free from seizures; 
sometimes the reverse occurs. Intercurrent diseases, as certain 
fevers or facial neuralgia, seem to protect for the time being 
against a paroxysm. During the intervals between the seizures 
the general health may be good; as already stated, there may 
be some deviation from the normal in the patient's mental con- 
dition, and there is always in well marked cases danger of 
mental failure; usually, moodiness, mental dullness or irrit- 
ability, slowness of comprehension, with failure of memory, are 
easily distinguished; but care must be taken to distinguish be- 
tween peculiarities of temperament or person and the effects of 
the disease. 

Jacksonian epilepsy (partial or cortical epilepsy) consists of 
convulsions which are limited to one-half of the body or to a 
single limb, to the face or to a group of muscles; there is not 
usually loss of consciousness. Its aetiology embraces irritation 
in the motor zone from any cause; meningeal inflammation, 
syphilitic neoplasms, pressure upon the cerebral cortex from 
fracture of the skull, cerebral lesions of vascular origin, uraemia, 
progressive paralysis of the insane, and peripheral irritation 
acting upon the nerves of the extremities, trunk or viscera, 
especially the pleura. 

The spasm is rarely preceded by an aura, which, if it occurs, 
usually consists of a sense of numbness, possibly pain, in the 
part to be affected. Consciousness is nearly always retained if 
the epilepsy is truly partial. The convulsions usually start in 
the face or extremities. If in the face, they ma}' center in the 



GENERAL AND FUNCTIONAL DISEASES. 459 

eyes or mouth, but practically involve the entire face, extending 
to the neck, possibly to the arms and legs. If in the arm, the 
thumb and index finger, later all the fingers, are convulsively 
flexed into the palm of the hand; the muscles of the forearm are 
then involved, then those of the arm and shoulder; should the 
spasm extend beyond this, it next seizes the muscles of the neck 
and face, then the leg. If the seizure starts in the leg, it begins 
with the big toe, extending upward, causing movements of ex- 
tension in the upper, and movements of flexion in the lower, leg. 

The spasms vary much in severity; as in general epilepsy, the 
condition of the affected muscles is first tonic, then clonic; the 
seizure is followed by a brief period of stertor and exhaustion. 
In light seizures, as in the arm, the patient is not only conscious, 
but may continue to talk and complete any task at which he 
may happen to be engaged; if the spasms become general, con- 
sciousness is lost during the latter part of the seizure. Some- 
times there is invasion of the corresponding muscle on the side 
opposite to that first attacked. Muscular exhaustion, amount- 
ing to transient or even permanent paralysis, may follow. 

The attacks recur at long intervals, of several weeks or 
months, but exceptionally much oftener, even daily; in the same 
person they maintain the same form and order of development. 
Rarely they assume a status epilepticus, in which case they 
may prove fatal. 

Diagnosis. — Usually it is not difficult to recognize the major 
form of epilepsy; in many respects, however, it resembles hys- 
teria. The table on the following page, from Gowers's work, 
clearly shows the most important points of differentiation: 

The difference in the manner in which the hysterical patient 
falls and the relief occasionally experienced from ovarian com- 
pression are also points to be remembered. Ursemic convul- 
sions axe characterized by greatly increased tension and may 
be recognized from examination of the urine. The age of the 
patient must be taken into consideration. For certain illegiti- 
mate purposes persons may simulate epilepsy; this is often done 
in Europe to escape military duty. If the malingerer is deter- 
mined and skillful, it may tax a careful diagnostician to expose 
the deception. Wood points out that the violent muscular 
efforts made can dilate the pupils, but that they will contract 
to the stimulus of light, and that snuff blown into the nostrils 
will cause sneezing in the sham-epileptic. 



460 



DISEASES OF THE NERVOUS SYSTEM. 



Prognosis. — Epilepsy is essentially a life-long disease; though 
the patient has been free from attacks for years, they may recur 
through some special excitement or imprudence, and even with- 
out apparent cause. It is largely on this account that treat- 
ment should be maintained indefinitely, and the patient be kept 





Epileptic . 


Hysteroid. 


Apparent cause. 


None. 




Emotion. 


Warning. 


Any, but especially unilat- 
eral or epigastric auras. 


Palpitation, malaise, chok- 
ing, bilateral foot aura. 


Onset. 


Always sudden. 




Often gradual. 


Scream. 


At onset. 




During course. 


Convulsion. 


Rigidit}', followed by "jerk- 
ing, ' ' rarely rigidity alone. 


Rigidity or "struggling," 
throwing about of limbs 
or head, arching of back. 


Biting. 


Tongue. 




Lips, hands, or other people 
and things. 


Micturition. 


Frequent. 




Never. 


Defecation. 


Occasional. 




Never. 


Talking. 


Never. 




Frequent. 


Duration. 


A few minutes. 




More than ten minutes; 
often much longer. 


Restraint neeessar3'. 


To prevent accident. 




To control violence. 


Termination. 


Spontaneous. 




Spontaneous or induced 
(water, etc.). 



underdose observation for j r ears after the seizures have ceased. 
Death during a paroxysm occurs only as the result of an acci- 
dent, such as injury from the fall, or smothering under the bed- 
covering or in the pillow, or by getting food into the windpipe 
if at the table when a paroxysm occurs. Epilepsy, however, 
shortens the life-expectancy, the subject usually dying from 
some intercurrent disease. The affection is always to be con- 
sidered serious and a cure uncertain. In young children re- 
covery is not unusual, and maybe spontaneous and permanent; 
but even adults, particularly men, may be cured. Favorable 
to a cure are: earty intelligent treatment as soon as the nature 



GENERAL AND FUNCTIONAL DISEASES. 461 

of the disease is ascertained; infrequency and mildness of the 
attacks; improvement, under treatment, of the general health, 
of the mental condition, and of the memory. Unfavorable are: 
occurrence of grand mal and petit mal in the same case; a his- 
tory of epilepsy covering many years ; intensity of the individual 
attacks and prolonged stertor; marked mental failure. Judg- 
ing from my own experience in adults, a general improvement 
in health and in the mental sphere, even though slow, following 
the treatment, and not accompanied with material lengthening 
of the intervals, yet constitutes an encouraging sign. 

In Jacksonian epilepsy the prognosis is much better, save 
when epilepsy results from the presence of a cerebral tumor, 
with symptoms of compression, in which case it is bad. Epi- 
lepsy due to a peripheral lesion may or may not be cured by its 
removal; the convulsive habit once established, the removal of 
the primary cause may not effect the course of the disease. 

Treatment. — The nature of epilepsy, the frequency with which 
it occurs, and the comparative hopelessness which settles like 
a pall upon the epileptic patient and his family, all appeal 
strongly to the medical profession for an effective method of 
treatment. It is humiliating to admit that after centuries of 
honest and unflagging endeavor only slight progress has been 
made in this direction. The following is a summary of what is 
now considered the most promising management of a case. 

The general treatment consists of careful attention to the 
habits of the patient, including diet and regular sponging in 
cold water, followed by brisk rubbing of the skin. Pains must 
be taken to provide agreeable occupation, and, whenever possi- 
ble, some regular employment which is free from danger to the 
patient in case he is suddenly taken with a seizure. Overexer- 
tion of any kind, whether physical or mental, and excitement, 
including active society life, are to be scrupulously avoided. If 
circumstances admit, an attendant should be provided, but it 
is well to avoid the appearance of constant watching; if such 
an attendant can not be had, care must be taken to have some 
member of the family keep a sharp watch upon the epileptic, 
lest he may seriously hurt himself by falling into the fire, against 
a hot stove, out of a window, or from a height. The same care 
must be exercised at night, in bed, since a patient may be 
smothered under the bed covering or by pressing the face firmly 



462 DISEASES OF THE NERVOUS SYSTEM. 

into the pillow. Under no circumstances should the patient be 
allowed to go alone into a bath; swimming, bicycling and 
horse-back riding are, of course, out of question. Dancing or 
swinging cannot be allowed, since these exert a disturbing 
effect upon the cerebral circulation. The diet should be plain, 
but nourishing. Experience proves that vegetables, ripe fruit 
and milk are to be preferred to a meat diet; the latter often 
does positive harm. Meat once a da3 r is not objectionable. 
Sexual excitement is harmful. Alcoholic stimulants of any sort, 
tea and coffee must be used with great moderation, if at all; 
the same applies to tobacco. The long-continued use of cod- 
liver oil has proved beneficial to thin, anaemic subjects. The 
value of internal medication depends very largely upon the 
faithfulness with which these general rules are observed and 
the perseverance exercised by the family in following treatment. 
Since the introduction ; of the bromides in the treatment of 
epilepsy (1853), these have, in the medication of the profession 
at large, gradually supplanted all other drugs. If their em- 
ployment has fallen far short from accomplishing what was 
expected of them, it has certainly been demonstrated that in 
some cases they suppress the spasm and occasionally for a long 
time prevent its recurrence. Authorities differ concerning the 
manner in which the bromides should be given in order to 
obtain the best results. It is, however, freely admitted that 
they should be administered in large doses, repeated not oftener 
than three times a day (after each meal), and many experienced 
practitioners hold that it is even better to give only one large 
dose just before retiring. Unpleasant effects, chiefly upon the 
mind, follow their exhibition in small doses and at short in- 
tervals. Of late, sodium bromide is preferred to the potassium 
bromide because it is more readily borne by the patient. Others 
prefer a solution containing the bromides of potassium, am- 
monium, and sodium. Hirt, who has had large experience, 
states that the moderate doses formerly used, from eight grains 
to one drachm, are generally ineffectual, and he advises one 
daily minimum dose, for adults, of two drachms, also indors- 
ing Mendel, who gives it in valerian-tea immediately before 
going to bed, in the following proportion: of pot. bromide and 
ammon. bromide, thirty-eight grains each, of sod. bromide, 
fourteen grains. If two-drachm doses are not sufficient, Hirt 



GENERAL AND FUNCTIONAL DISEASES. 463 

increases it gradually to three drachms, and continues it until 
from six to nine ounces have been taken. Other authorities 
continue the salt in daily doses of one drachm to a drachm and 
a-half for years, even for two years or more after the seizures 
have ceased. One of the first indications that the system has 
come under the influence of the drug is loss of the palate reflex, 
and it is necessary to reach this point. Many persons cannot 
take the drug at all, and absolutely refuse it after having taken 
a few doses; in others it causes great muscular and mental 
lassitude, constant sleepiness, loss of memory and melancholy, 
necessitating a lessening of the dose. Acne on the face, extrem- 
ities and trunk is a common drug-effect; it can be prevented by 
giving the bromide in alkaline waters and occasionally admin- 
istering a full dose of arsenic (Seguin) . The sudden withdrawal 
of bromides, according to Fere, is exceedingly risky and may 
result in the recurrence of the paroxysms, assuming even 
the form of the dangerous status epilepticus. The bromide of 
strontium has given satisfactory results and causes no gastric 
irritation. Bromide of camphor has proved useless. During a 
course of bromides the occasional exhibition of belladonna is 
highly recommended. (Extr.bell., grs. viiss; Pot. brom., Sodii 
brom., Ammon. brom., aa gss; Pulv. et. succ. liq., aa q. s. ut. f. 
pil.No.50. Signa: One to two pills in the evening.) Hammond 
advises bromide of zinc, in a solution of one drachm in one 
ounce of simple syrup, from 10 to 30 drops three times a day. 

Electricity has been employed by passing the galvanic current 
from one mastoid to the other or obliquely from one frontal 
region to a point diametrically opposite at the nucha; for this 
method also no satisfactory results can be claimed. 

Epilepsy arising from reflex action may demand surgical in- 
terference. Thus a cure may result from the removal of a 
splinter of bone causing cortical irritation, from the excision of 
a cicatrix, the relief of an adherent prepuce, or from circum- 
cision, or from the stretching of a tight sphincter ani. Such 
cures, however, are very rare, and it is a serious question if the 
interest created by them has not in the long run been calamitous 
rather than beneficial to the sick, in so far as many operations 
have been performed which were not indicated or excusable. 

The treatment of the spasm itsell is simple. If sufficient time 
elapses between the aura and the spasm, an attempt may be 



464 DISEASES OF THE NERVOUS SYSTEM. 

made to abort the latter by firmly bandaging the extremity 
from which the aura precedes or by vigorously rubbing the part 
from which it emanates. If the aura is epigastric, a big pinch 
of salt taken at once may abort the fit. Sometimes the inhala- 
tion of amyl nitrite answers the same purpose. But oppor- 
tunity^ for the employment of such measures is afforded only 
in exceptional cases, and their actual value is not great. Indi- 
cations of a convulsion presenting themselves, the patient 
should be gently laid on the floor, the clothing loosened, espe- 
cially about the throat, fresh air admitted into the room, and 
some firm substance (rubber ring) be placed between the teeth 
to protect the tongue. If the convulsions are prolonged, a 
few whiffs of chloroform or amyl nitrite may help cut the at- 
tack short. 

So far as strictly homoeopathic treatment of epilepsy is con- 
cerned, an immense amount of clinical testimony has accumu- 
lated to prove the certainty and rapidity with which the dis- 
ease can be cured by "the indicated remedy." Unfortunately, 
here as with the wonderful cures published by enthusiasts in 
other schools, an unbiased examination shows that usually 
the cases reported cured were not epilepsy- at all or that the 
report was made long before an experienced practitioner would 
dare admit, even to himself, that a cure had been accomplished. 
Nevertheless, I am thoroughly satisfied that infinitely better 
results are obtained under the "homoeopathic" treatment of 
epilepsy than can be claimed for the treatment with bromides, 
provided the physician in charge possesses sound judgment, 
close observation and patience, and is dealing with a case 
which renders it possible to strictly carry out the general direc- 
tions already considered. 

It is very important to have the physician rid himself of the 
impression that the spasm itself will furnish him with "indica- 
tions" upon which to base the selection of the remedy, or that 
at some time or other there will present itself with unmistaka- 
ble plainness some "grand characteristic" which will enable 
him to pounce upon the remedy of which one dose will cure a 
case of many- years' standing. It is true that in very many 
cases there is some one remedy which appears to underlie all 
permanently curative attempts. That remedy is usually- found 
in the "constitutional bias" of the patient, in temperamental 



GENERAL AND FUNCTIONAL DISEASES. 465 

peculiarities which may to the careless observer appear trifling, 
in his preferences or dislikes, and will often betray itself in the 
small doings of daily life which the physician must observe, but 
which no list of carefully framed questions can elicit. This fact 
explains why Calcarea carbonica, Silica, and other pro- 
foundly acting remedies which in provers have never produced 
a condition like true epilepsy are often of inestimable value 
when the so-called antispasmodics are perfectly useless. 
Further than this, the utmost watchfulness must be exercised 
in promptly meeting such derangements of health which in a 
normal condition may be of no moment, but in an epileptic prove 
the reverse. A tendency to headache, which may appear so 
trifling that it is not considered worth mentioning to the 
physician, or a slight uneasiness at the heart, or light palpita- 
tion with, possibly, gastric flatulency of very moderate degree, 
or occasional states of biliousness scarcely enough to attract 
passing attention, must be met promptly and may suggest 
some remedy which otherwise would not be considered, but 
which here may greatly facilitate a cure. Thus Gelsemium did 
permanent good in a case "which has been under my observa- 
tion for over ten years, and in which there is promise of a cure; 
the remedy was suggested by slight but frequent headache 
with a tendency to drooping of the eyelids, flushed face, dizzi- 
ness, and general muscular weakness. In a similar manner 
Asa fcetida, Moschus, Pulsatilla, and others may be indi- 
cated by mild gastric or nervous symptoms, and prove very 
helpful. It is often the case that an epileptic patient will not 
of his own accord mention minor ailments like this; their very 
recognition depends upon the watchfulness of the physician. It 
might be asserted that the attention which is paid to "small 
things" holds the promise of a cure. 

Another point is the necessity of not only having the patient 
under constant treatment for years, but so long- as there is 
actual improvement. The patient and his friends will naturally 
measure the latter only by the relative frequency and severity 
of the convulsive paroxysms; and yet, this standard may be 
wrong. I would lay down the axiom that a patient is making 
unqualified gain if under treatment there is an improvement in 
the mental and moral sphere, especially if there is less moodi- 
ness and irritability than formerly, and if the perceptive facul- 
30 



466 DISEASES OF THE NERVOUS SYSTEM. 

ties and the memory are more vigorous; this is true even though 
there be no material lengthening of intervals or lessening in the 
severity of the spasms. 

Several writers suggest the wisdom of having a record kept 
by some friend, in which are entered the date of the spasms had 
and the conditions connected with it. The suggestion is prac- 
tical and valuable, as I can testif}^ from my own experience. 

Calcarea carbonica, Calcarea phosphorica, Silica and 
Sulphur are to be given as "constitutional" remedies when 
the general condition of the patient warrants their exhibition. 
It is not necessa^ here to point out the symptoms covered by 
each. — Argentum nitricum when the attacks are the result of 
fright or occur about the menstrual period; in persons who 
have been guilty of alcoholic and venereal excesses. Tremulous 
anxiet}^ and restlessness before and after a spasm. Great mel- 
ancholy; dreads being left alone. The characteristic gastric 
symptoms, especially flatulency with palpitation, are very im- 
portant. — Belladonna. Violence of convulsions; characteris- 
tic congestion to head and face; in persons of light, florid com- 
plexion. Bojanus and the older homoeopaths report many 
cures with Belladonna. It undoubtedly is of great value in 
recent cases; its relation to states of violent cerebral conges- 
tion, often with characteristic delirium and mania, render it 
helpful in acute attacks characterized by these, but it is of 
slight benefit in old and well-established cases. — Bufo (Rana 
bufo) appears to have permanently cured a number of cases. 
It is said to be indicated when seizures occur at the menstrual 
period or are precipitated b} r sexual excitement. The aura 
starts from the sexual organs or solar plexus. The patient is 
easily angered, feels cold a good part of the time. Saville, Hol- 
combe and many others thought it an excellent remedy; my 
experience with it has not been conclusive. — Cuprum metalli- 
cum has given positive results, in my experience, in three cases, 
all of long standing and in women, when menstruation invari- 
ably brought on a spasm or was within a week followed by a 
violent paroxysm. In all the cases coldness was marked; in 
two of them the spasm was followed by violent headache, 
with coldness in the brain. In one of them my attention was 
called to Cuprum by frequent attacks of convulsive cough, with 
extreme blueness of the face, resembling whooping cough, when- 



GENERAL AND FUNCTIONAL DISEASES. 467 

ever she took cold. — Glonoine resembles Belladonna; it often 
is serviceable in petit mal. — Hydrocyanic acid is helpful in 
epileptiform convulsions rather than in true epilepsy. T. F. 
Allen says: Epileptic attacks preceded by nausea, vomiting, or 
waterbrash. In recent cases. — Hyoscyamus covers the same 
ground, i. e., there is violent convulsive action, but not true 
epilepsy. Yet, in several recent cases, in children, it has ren- 
dered me good service. I have found it especially useful when 
the spasm leaves the patient with a severe, stupid headache, 
slightly wandering, inclined to talk a good deal, or with long- 
continued stupor. In patients who regularly present these 
symptoms a spasm is sometimes preceded by a similar head- 
ache, with livid face and rather sparkling eyes, dizziness and 
ringing in the ears; if so, five-drop doses of the mother tincture 
in water, repeated once or twice, have aborted the threatening 
seizure.— Ignatia, like Asa fcetida, Moschus, Nux moschata 
and Nux vomica, does not directly affect the spasm, but I have 
rarely managed a case of epilepsy in which these remedies were 
not frequently demanded by the symptoms of the case. When 
there is much nervous tension and irritability, Ignatia is invalu- 
able. The indications for these remedies are familiar to all. — 
CEnanthe crocata, so highly praised by Hale and others, has 
in my hands proved without the slightest value. I am com- 
pelled to report the same concerning Solanum carol., which I 
have given in every possible dose without the slightest bene- 
ficial effect. In one case it seemed to arrest the paroxysms, but 
mental enfeeblement progressed with astonishing rapidity. — 
Zincum has done good service in some cases of infantile epilepsy, 
and is thought to be of value, upon theoretical grounds, in 
cases induced by cerebral exhaustion. The profound action of 
this metal upon the brain and nervous system generally war- 
rants the hope that it may be found useful in the treatment of 
complications and effects of epilepsy involving the nerve centres. 
In the epilepsy of children and in recent cases all the remedies 
producing marked convulsive action are to be studied (see also 
hysteria). Cina, Chenopodium, Stannum and Indigo are par- 
ticularly useful when there is irritation from intestinal para- 
sites. 

INFANTILE CONVULSIONS (Eclampsia). 

Infants and quite young children are frequently the subjects 



468 DISEASES OF THE NERVOUS SYSTEM. 

of violent convulsions, vanning in severity from slight jerking 
and twitching of the face and extremities, without loss of con- 
sciousness, to spasms which in every respect resemble epilepsy. 
The general predisposition to eclampsia on the part of infants 
undoubtedly" rests upon the incomplete development of the ner- 
vous system at this tender age. Special predisposing causes 
may be found in an inherited instability of the nervous system 
and in such constitutional states as rickets (seen in from 30 to 
40 per cent.), anaemia, and great physical weakness. The ex- 
citing causes are chiefly reflex. Of these, the irritation arising 
from dentition (irritation in the 5th pair), especially in feeble 
children and during the first six months of life, and that due to 
an overloaded stomach or a stomach filled with indigestible food, 
are clinically of particular importance. Other causes are: otitis, 
phimosis, adherent prepuce or clitoris. It is generally recog- 
nized that in fevers of children convulsions largely take the 
place of chills in adults; there are infants in whom even a slight 
fever is sure to excite convulsions. This peculiar tendency is 
especially noticeable in infectious fevers, particularly in scarlet 
fever, measles, malarial fever and pneumonia, the onset of 
wmich is often marked by violent general convulsions. Again, 
convulsions occur in connection with meningitis, simple and 
tubercular, spinal paralysis, tumors and other cerebral lesions; 
rarely, if ever, from simple cerebral congestion. Not infre- 
quently they are seen in the late stage of entero-colitis. Scalds, 
burns, fright, anger, or any unusual excitement may be followed 
by eclampsia. Convulsions may occur soon after birth, and 
then are usually the result of injuries received during labor, as 
meningeal haemorrhage from the use of forceps, or of congenital 
disease (heart disease or atelectasis). 

Symptoms — Infantile convulsions may be local or general. 
The local form finds its type in laryngismus stridulus, which is 
elsewhere described, and which may be accompanied with gen- 
eral rigidity or exceptionally may terminate in general convul- 
sions. 

General convulsions may be preceded by restlessness, espe- 
cially during sleep, starting and crying in sleep, twitching of 
muscles and grinding of teeth; oftener their onset is sudden 
and unsuspected. There is sometimes a sharp, warning cry, 
followed by spasmodic action in the (right) hand; then tonic 



GENERAL AND FUNCTIONAL DISEASES. 469 

rigidity of the body, with fixed, staring eyes; cessation of re- 
spiratory movements and lividity of the face; these are soon 
succeeded by general clonic movements with convulsed face, 
firmly closed jaws, rolling of the eyes, retraction of the head, 
and violent twitching or rhythmic flexure and extension of the 
arms. There may be frothing at the mouth and escape of 
bloody saliva from the mouth; the pupils are usually dilated; 
the face is livid, sometimes pale. After a time, in from one to 
three minutes, the convulsions gradually cease and the child 
passes into a sleep of profound exhaustion or stupor, from 
which it awakens in half an hour or hour. Consciousness is 
always lost when the convulsions are general. The tempera- 
ture is normal in laryngismus stridulus, but is raised when the 
convulsions are general. Exceptionally convulsions may 
rapidly succeed each other as in the status epilepticus; such 
cases are characterized by high fever. Death may occur from 
asphyxia, exhaustion, or central cause; exceptionally paralysis 
may result from haemorrhage of the meningeal vessels. 

Diagnosis. — The diagnosis deals with the probable cause of 
the convulsive seizure. As stated, when convulsions occur soon 
after birth, they are the result of congenital disease or of injury 
received during parturition. In a child more than six months 
old the cause probably lies in difficult dentition or gastro- 
intestinal irritation. If localized, i. e., limited to one side or 
one extremity, they indicate a localized organic lesion in or 
near the motor cortex. The presence of high fever and vomit- 
ing is characteristic of brain lesion or the onset of scarlet, or 
other infectious, fever. If convulsions set in some weeks after 
the cessation of an eruptive fever, or if no satisfactory explana- 
tion can be found, the urine should be examined for albumin. 
If convulsions appear after the second year, without apparent 
cause, in a child which otherwise seems healthy, epilepsy may 
be suspected. 

Prognosis. — Convulsions in children must never be treated 
lightly. Frequent recurrences, it is true, do not necessarily 
mean permanent ill health or death, but the first paroxysm 
may prove fatal. If reflex or occurring as a complication of 
rachitis, the prognosis is favorable. If occurring at the onset 
of eruptive fevers, they are less serious than when occurring 
later; in scarlet fever they always constitute a threatening 



470 DISEASES OF THE NERVOUS SYSTEM. 

feature. If complicating the last stage of cholera infantum, 
especially in a child which lacks in vitality or which is unusually 
exhausted, the prognosis is bad. General convulsions in laryn- 
gismus stridulus and in toxaemia are very serious. Hyper- 
pyrexia with convulsions is a grave symptom. 

Treatment. — The treatment of the individual case is governed 
by the cause of the convulsions. When the stomach or bowels 
are overloaded, they should be promptly emptied; vomiting 
may be produced by tickling the fauces, but there is an element 
of possible danger from food entering the windpipe. Should 
the gums be hot, badly swollen, painful and tough, lancing is 
advised; I share the increasing prejudice against this seemingly 
inoffensive measure, because I never have seen good come from 
it. Firm pressure over the abdomen, when the first symptoms 
of a seizure appear, is a favorite measure of old nurses, and 
often aborts an attack. A tepid bath, not hot, is always in 
place; if, for some good reason, it cannot be given, a mustard 
foot-bath is a good substitute. Hyperpyrexia calls for hydro- 
therapy; cool packs, repeated, are recommended; I prefer a 
warm bath, followed by wrapping the child in a sheet wrung 
out of tepid water, with a flannel outside, to be repeated when 
necessary. During the convulsion the child should not be re- 
strained; its true position is across the knees of the nurse, 
resting on the abdomen. A few whiffs of chloroform are effect- 
ive in controlling the severity of the convulsions. 

Belladonna is indicated frequently and nearly always acts 
promptly. It is useful in the convulsions of scarlet fever, mea- 
sles, meningitis, difficult dentition, and gastric irritation. The 
face is congested and hot; the convulsions violent, with froth- 
ing at the mouth. Teething is difficult and the mouth and gums 
are hot, red, dry, swollen; there is fever, with restless sleep, in- 
terrupted by frequent starting and jumping, with twitching of 
limbs; the head is hot and the child lies with half closed eyes, 
rolling and restless; the pupils are dilated. (Glonoin bears a 
close resemblance to Belladonna and gives rise to violent 
cerebral congestion, but it is nevertheless of slight value here). 
— Cuprum. Localized or general convulsions. Convulsions 
during the late stage of eruptive fevers, especialh' scarlatina, 
and when there is retrocession of the rash. Meningitis. Laryn- 
gismus stridulus. The convulsions begin with contractions in 



GENERAL AND FUNCTIONAL DISEASES. 471 

fingers and toes, and become violent in character. The child 
bites the spoon when efforts are made to give it medicine. The 
bodily surface is cool and bluish. — Cina. Invaluable when con- 
vulsions occur from intestinal irritation caused by the presence 
of worms. Tonic rigidity is pronounced during the fit; pallor 
of the face. The typical ciNA-patient has hard and distended 
abdomen and is a voracious, though somewhat fitful, eater; he 
is nervous, fretful, excitable and aggressively cross, striking at 
his nurse, and hard to take care of; there is picking at the nose, 
muscular restlessness, enuresis; the face is hot and red, or red 
on one side, pale on the other; often great pallor about the 
mouth and nose. — Cicuta is not so frequently indicated, but is 
serviceable when convulsions are caused by worms, indigestion 
(oesophageal spasms from worms) or by meningeal inflamma- 
tion. The convulsions are tetanic, involving the muscles of the 
face and the whole body; the child lies insensible, with staring 
eyes, face red, hot and sweaty; frothing at the mouth; con- 
vulsions are brought on by the slightest jar. — Opium is sug- 
gested in the rarer cases where an apoplectic state exists. The 
face is purplish and breathing stertorous. The body is hot and 
bathed in a hot sweat. Convulsions from fright, beginning 
with a loud cry. In children who are habitually constipated 
and in whom soap-and-water injections have been daily used. 
— Stramonium. In the suffocative spasms of severe whooping 
cough, with tendency to convulsions; from fright. Decidedly 
choreic action; the limbs are in constant convulsive motion. 
The child appears strangely nervous; the slightest disturbance, 
as the approach of a stranger, frightens it out of its wits and 
threatens to bring on spasms. — Zincum must be studied in the 
convulsions of anaemic teething children, partaking of the nature 
of epilepsy, when there is reason to suspect cerebral disease. — 
Nux vomica suggests itself when the convulsions are tetanic in 
character and caused by indigestion. — ^Ethusa has cured the 
convulsions of cholera infantum, so-called, when there was 
present vomiting of large, solid chunks of curdled milk. — 
Aconite is indicated by its characteristic excitement and 
anxious tossing about, with fever, heat, and thirst; it is useful 
when the convulsions occur during the onset of an eruptive 
fever or from fright. It is differentiated with difficulty, in these 
cases, from Belladonna; it covers a narrower field of action 



472 DISEASES OF THE NERVOUS SYSTEM. 

than Belladonna, with less active congestion, not 3^et local- 
ized. — GELSEMIUM is suggested when convulsions occur in chil- 
dren who are living in malaria-infected countries, in which case 
important objective symptoms of the remed}' can be recognized, 
as: great prostration, with almost paralytic weakness of the 
extremities; fever with much heat and hot sweat; the child lies 
half-stupid, indifferent to everything about it; acts as though 
it felt dizzy; pupils usually dilated. It is said to be useful in the 
convulsions of measles, with catarrhal symptoms of the eyes, 
nose and throat. 

Passiflora has been used empirically, in large doses, and 
favorable reports of its action have been published. I have no 
experience with it. 

ACUTE CHOREA (St. Vitus's Dance). 

The term "choreic movements," according to H. C. Wood, is 
applied to "irregular movements produced by independent con- 
tractions of single or associated groups of muscles, not vibra- 
tory in character, and more or less simulating purposive move- 
ments, but never forming a complicated series of apparently 
purposive actions. They may vary in intensity from the 
slightest irregular movements of the fingers or toes, or even a 
mere condition of excessive muscular activit}* - resembling rest- 
lessness, up to the most severe and violent motions. They 
may be confined to a single group or to associated groups of 
muscles {local chorea) or may affect the entire muscular system 
{general chorea). When the whole body is affected, the muscu- 
lar contractions do not take place regularly or consenta- 
neously, but momentarily, here or there. In some cases they 
are under the control of the wall for a short period of time, but 
always arrest themselves in a few minutes. The choreic move- 
ment is usually irregular, but it may be rhythmical. Rhythmi- 
cal choreas more or less closely resemble tremors, differing 
chief!}' in that the movements are much slower and more ex- 
tensive." 

Acute chorea (Sydenham's Chorea) or St. Vitus's dance is a 
non-febrile disease, chiefly of children, characterized b} r general 
choreic movements with loss of nerve-energy and muscular 
power and by psychical disturbances. 

^Etiology. — St. Vitus's Dance in about eight^^ per cent, of all 



GENERAL AND FUNCTIONAL DISEASES. 473 

the cases occurs between five and fifteen years of age and at 
least twice as often in girls as in boys; it is, however, occa- 
sionally seen in infancy and later in life. It is infrequent among 
the negroes and not known among the Indians. The greater 
number of cases occur during the months of spring. A family 
tendency to chorea undoubtedly exists in many cases. A his- 
tory of rheumatism is often found, arthritic affections either 
having preceded chorea by some months or years or being im- 
mediately associated with it; the frequency of organic disease 
of the heart in both diseases emphasizes the close connection be- 
tween them. In a majority of cases the neuropathic tendency 
is evident; hence, any influences or conditions which irritate 
or tax the nervous system may become exciting causes; thus 
fright, worry, grief, mental trouble of any kind, injudicious ap- 
plication to school-work, and unwholesome living, as found 
especially among the children of the poor, are important 
factors. To these may be added the exhaustion following in- 
fectious diseases of childhood, as scarlet fever or, according to 
Sturgis, whooping cough, injuries or slight operations, also 
reflex irritation, as from worms, phimosis, hooded clitoris, etc. 
Among adults, pregnancy, particularly the first five months of 
a first pregnancy in a woman less than twenty-five years of 
age, is classed among the less frequent causes. Chorea also 
occurs occasionally after abortion or delivery at full term. 

Morbid Anatomy and Pathology. — The essential anatomical 
cause of chorea has not yet been discovered. No constant lesions 
in the nervous system have been found. In very many cases 
endocarditis, nearly always simple, sometimes ulcerative, is 
seen after death, associated with embolism of the smaller 
arteries of the brain. So frequent is this that Kirkes, and 
others, believe that cerebral embolism constitutes the distinctive 
pathological feature of the disease. However, endocarditis, 
though a frequent, is by no means a constant feature of 
chorea, and when present is not always associated with the 
existence of cerebral embolism. 

The independence of chorea of profound organic changes in 
the brain is proved by the short duration of the disease in some 
cases and its rapid recovery; on the other hand, the absence of 
fever and the occurrence of chorea chiefly at a time of life when 
the nervous system is particularly sensitive and irritable, and 



474 DISEASES OF THE NERVOUS SYSTEM. 

in persons of the female sex, whose nervous organization, as a 
rule, is more easily disturbed than that of men, — these facts are 
cited in support of the theor}- that the root of the disease lies 
in the irritable state of the nerve centres which control the 
motor apparatus. The latter view appears plausible. The 
existing irritability of the nerve centres ma}- be caused by 
hypera-mic, anaemic or psychical influences or irritation from 
the periphery or centre. H. C. Wood believes that the essential 
pathological feature of chorea lies in an altered nutrition of the 
ganglionic structures of the cerebro-spinal axis, sometimes not 
sufficient to produce structural changes recognizable under the 
microscope, in other cases capable of giving rise to pronounced 
structural changes. The theory of the microbic origin of St. 
Yitus's dance is not yet substantiated by facts. 

Symptoms. — While acute chorea ma}' be sudden in its onset, 
it is usualh' preceded by general indisposition, digestive dis- 
turbances, often headache, and sometimes pain in the limbs, 
associated with a peculiar restlessness and inability to keep 
still for any length of time which is well expressed by the com- 
mon term "fidgets." With it there is more or less peevishness 
and irritabilit}', often in striking contrast with the previous 
even disposition of the child. The first symptom of motor dis- 
turbance shows itself in the hand, most frequently at the table, 
where the patient unexpectedly drops and breaks glasses or 
plates; the face soon afterward becomes involved. In slight 
cases the affection is limited to one limb, or to the face and one 
limb, with no marked constitutional sjmiptoms. 

In severe forms the muscular incoordination is sufficient to 
render the patient helpless. He is wholly unable to control the 
muscular movements, which spread from the arms and face to 
the legs and head, later involving those of the trunk; these may 
be general or one-sided (hemichorea), with a preference for the 
right side of the body, or they ma}- affect one arm and the leg 
on the opposite side. In such cases the arms are constantly 
and grotesqueh- thrown about in every direction, rendering it 
impossible for the child to dress or feed herself; the legs are 
affected in the same manner, and attempts to walk result in 
irregular, jerky movements in almost any direction, frequently 
lateral or zigzag, but always beyond the control of the patient; 
the face is distorted into constantly and rapidly changing 



GENERAL AND FUNCTIONAL DISEASES. 475 

grimaces; the tongue may be thrust about the mouth or 
rapidly forward, at times causing a clucking or clacking sound; 
the head is jerked forward or backward, to one side or the 
other, sometimes quickly rotated; speech becomes laborious 
and indistinct from difficult articulation, and may degenerate 
into a mere jumble of sounds without meaning, if the dis- 
couraged child does not eventually cease all efforts to talk; 
mastication and deglutition in some instances are seriously 
interfered with; involvement of the respiratory muscles, which 
usually occurs last and in some cases when speech is not affected, 
gives rise to paroxysms of hard, labored, sighing, sobbing 
breathing. The choreic movements may be of sufficient violence 
not to allow the child to lie on the couch or in bed unless held 
there by straps. During sleep the movements usually cease, but 
the difficulty of going to sleep may be so great as to rob the 
child of much-needed rest and greatly add to the already ex- 
isting debility. There is an increase of electric irritability of 
nerve and muscle on the affected side. Pain is rare, save when 
arthritic complications exist, although in some cases, espe- 
cially of hemichorea, there may be severe pain even in the ab- 
sence of rheumatic complications. Soreness to pressure is not 
uncommon, and "tender" points are present in some cases. 
There may be tingling and prickling sensations; anaesthesia is 
infrequent. 

Psychical disturbances are rarely severe. They usually con- 
sist of the irritability and peevishness already described. Some- 
times there is acute melancholia; hallucinations of sight and 
hearing are somewhat characteristic of hysterical cases; occa- 
sionally there is loss of memory and intellectual power, which 
very rarely may progress to dementia. In exceptionally severe 
cases mania may suddenly appear; as in the case of adult 
women (pregnancy), it constitutes a very threatening symp- 
tom. Fever is quite rare, save when chorea is associated with 
arthritis; moderate fever may result from unusual nervous 
excitement in a fretful, sensitive child. Cutaneous affections 
usually depend upon the presence of rheumatic troubles; but, 
independent of these, we may find herpes zoster, erythema 
nodosum and purpuric urticaria. The subcutaneous fibrous 
nodules which British observers describe occur in cases asso- 
ciated with rheumatism. — The Heart. There is rarely pain, 



476 DISEASES OF THE NERVOUS SYSTEM. 

but rapidity of the heart's action is common. Alurmurs may 
be heard; of these the soft, blowing systolic murmur at the 
base or apex is common in anaemic girls. The frequency of 
chronic valvular lesions and of acute endocarditis in choreic 
patients must be borne in mind, but it must also be remem- 
bered that post-mortem examinations have repeatedly demon- 
strated the absence of valvular lesions when the characteristic 
murmurs had existed during life. It has been suggested that 
in such cases the murmurs are due to irregular contractions of 
the chordae tendinae which prevents the proper closure of the 
valves. Osier gives the following hints: "In thin, nervous chil- 
dren a S3^stolic murmur of soft quality is extremely common at 
the base, particularly at the second left costal cartilage, and is 
probably of no moment. A systolic murmur of maximum inten- 
sity at the apex, and heard also along the left sternal margin, 
is not uncommon in anaemia, enfeebled states, and does not 
necessarily indicate either endocarditis or insufficiency. A 
murmur of maximum intensity at apex, with rough quality, 
and transmitted to axilla or angle of scapula, indicates an 
organic lesion of the mitral valve, and is usually associated 
with signs of enlargement of the heart. When in doubt, it is 
much safer to trust to the evidence of eye and hand than to 
that of the ear. If the apex beat is in the normal position, and 
the area of dulness not increased vertically or to the right of 
the sternum, there is probably no serious valvular lesion. The 
endocarditis of chorea is almost invariably of the simple or 
warty form, and in itself is not dangerous; but it is apt to lead 
to those sclerotic changes in the valve which produce incompe- 
tency. Pericarditis is an occasional complication of chorea, 
usually in cases with well marked rheumatism." 

Duration and Prognosis. — The duration of the average case 
is from two to three months, but in many cases recovery pro- 
gresses much more tardily. Recurrences are proverbially fre- 
quent; it seems probable that this arises from the continued 
existence of the cause or causes which brought on the first 
attack, and from increased irritability of the affected nerve 
centres from the attack itself; cases associated with rheumatism 
are especially liable to recurrences. The muscular exhaustion 
and the mental dullness which are common features of chorea 
hardly ever prove permanent. According to Ranney, marked 



GENERAL AND FUNCTIONAL DISEASES. 477 

insomnia has an unfavorable effect upon the prognosis. Death 
from chorea rarely occurs in children; the most carefully compiled 
statistics place the rate of mortality at less than two per cent. 

Diagnosis. — It should not be difficult to recognize St. Vitus's 
Dance, save in rare cases occurring in adults. The antagonism 
between the spasmodic movement of the muscles and the 
willed effort is always apparent; the child may will to do one 
thing, but is irresistibly compelled to do something else; thus, 
she may at the table endeavor to carry a spoon to her mouth, 
but the choreic action of the muscles carries it to her cheek or 
forehead. Reflex chorea has points of irritation, as eye-strain, 
adherent prepuce or clitoris, nasal affections, etc. Habit- 
spasms are more or less under the control of the will and 
are more deliberate than those of St. Vitus's Dance. In 
hysterical chorea the movements are more rhythmical, and 
there is a pronounced tendency to rigidity of the affected 
muscles; the hysterical state is usually recognized without dif- 
ficulty. In paramyoclonus multiplex the spasms are bilateral, 
symmetrical, occur at intervals and are very violent, but the mus- 
cles of the body and of the proximal portions of the limbs are 
involved. During the intervals, fibrillary tremors of the affected 
muscles. The disease occurs at any age. 

Treatment. — Pains must be taken to give to all children of a 
neurotic tendency an abundance of out-door life, so as to make 
them rugged and hearty, and not to allow too close applica- 
tion to school-room work; by such means a predisposition to 
functional disease of the nervous system, including chorea, may 
be overcome. Chorea having declared itself, even though in a 
very mild form, the patient must at once be taken out of school 
and secluded so far as possible. If the spasms are at all severe, 
she should be kept in a recumbent position a good portion of 
the time, as quiet as possible in body and mind. Play-things 
should be allowed in bed; if too fretful to remain in bed, the 
child, dressed warmly, may be allowed to play on the floor, 
but must not run about the room. The presence of other chil- 
dren in the room excites the patient and must be forbidden. It 
is well to carefully examine the patient for possible sources of 
irritation (eyes, nose, genitals, etc.) and remove them at an 
early date. If there are signs of involvement of the heart, rest 
is doubly necessary. Rheumatic symptoms suggest the use of 



478 DISEASES OF THE NERVOUS SYSTEM. 

appropriate medication. The bowels should be kept open and 
the child fed regularly and abundantly; fats, cream, butter, 
olive-oil and cod-liver oil are strongry indicated. Long-con- 
tinued warm baths are helpful; they should be given at a tem- 
perature of 95° to 100°. Gentle massage, with olive-oil or 
cocoa-butter, should be given daily. If troubled with sleepless- 
ness, use hot sponge -baths or the hot bath; hypnotics should 
not be employed save as a last resort. If the parox3'sms are 
very violent, the bed should be thoroughly padded, so as to 
protect the child against injury; it may be necessary to strap 
the child down, but there are serious objections to this measure, 
and it should not be employed if it can possibly be avoided. 
Inhalations of chloroform may have to be used to control the 
spasms. In some tedious cases the rest-cure is often followed 
by rapid improvement; others demand a change of air (when 
possible, nearness to the seashore). During recovery great care 
must be used to maintain continuous improvement and to 
guard against relapse. Here, also, quiet, abundant and ap- 
propriate feeding and passive exercise (bathing, rubbing, mas- 
sage, carefully graded gymnastics in the room and alone) are 
very important. The friends must always be cautioned against 
the probable recurrence of the disease. 

Electricity^ is recommended by authorities; it has not been of 
service in my hands. Bartlett speaks highly of Dana's method, 
i.e., anodal galvanization of the brain. "The positive electrode, 
well moistened, is placed over the motor area on the side oppo- 
site to the one most severely affected by the movements. The 
negative electrode is then placed in the choreic hand. A mild 
current is permitted to pass without interruption for two or 
three minutes. If both sides are affected, then the sides of the 
electrodes are reversed, the positive one being still kept to the 
head, and the negative to the hand." 

Therapeutics. — Agaricus is one of the most important reme- 
dies. It is indicated when there is anaemia of the brain and 
cord; the choreic movements may occur in single muscles or be 
general; they are sometimes on opposite sides, i. e., right arm 
and left leg, and vice versa. The movements var} r in intensity 
from slight twitching of muscles to energetic, convulsive move- 
ments of the entire body. The spasms cease during sleep, but 
there is much jerking of muscles while she is going to sleep. 



GENERAL AND FUNCTIONAL DISEASES. 479 

The remedy has among its indications spasm of the muscles of 
accommodation and much twitching of the eyes and lids; 
twitching about the mouth and lips; herpetic eruption and 
soreness about the lips; tumultuous, excited action of the heart; 
copious emissions of inodorous flatus; burning-itching and red- 
ness of the skin, as though after a frost-bite. — AGARiciNE,in the 
lower triturations, is at present a popular empirical remedy in 
chorea. — Cuprum. Choreic movements very violent, almost 
convulsive; cerebro-spinal irritation; from fright, often with 
strongly marked hysterical manifestations. Spasms begin in 
the fingers and toes, are usually better from lying down, but 
continue somewhat during sleep. Difficulty of deglutition and 
of breathing from involvement of the muscles of the throat; 
cramps in the stomach and violent vomiting. Chlorosis, 
periodical chorea; painful cramps in the calves of the legs; 
paresis after chorea. — Ignatia. In emotional children, with 
characteristic mental state, faintness, debility excitability, 
"sinking" sensation at the stomach, great gastric flatulency. 
Spasms of the eye-lids (asthenopia); spasms of the facial 
muscles, brought on by attempts to speak. Tenderness to 
pressure along the spine. Incontinence of urine. Aggravation 
from any emotional excitement; from threats of punishment. — 
Hyoscyamus. General convulsive action strongly pronounced; 
every muscle of the body twitches and jerks; the arms are 
thrown about violently. Mental excitement; child is unrea- 
sonable, easily provoked to anger, demonstrative and violent; 
periods of excitement followed by great exhaustion. Chorea 
of pregnancy, with horrible dreams from which she awakens 
terribly frightened; sees vermin, bugs, hideous faces, etc., as 
soon as her eyes are closed. (Many practitioners prefer hyos- 
cyamine and hyoscine. )— Cimicifuga. Spinal irritation, muscu- 
lar rheumatism, with first appearance of menses, with aggra- 
vations during menstruation; irritable spine. Great mental 
depression. Chorea brought on by fright chorea of pregnancy, 
with pronounced melancholy. Sleeplessness. Chorea of the 
left half of the body. — Veratrum viride. In cases character- 
ized by violent congestion; spasms almost tetanic; tumultuous 
action of the heart. — Arsenicum. Of the greatest importance 
in tedious cases with profound anaemia, melancholy, "weak and 
rapid action of the heart, restlessness and anxiety. The high 



480 DISEASES OF THE NERVOUS SYSTEM. 

place it holds in the estimation of the dominant school in the 
treatment of chorea is based upon the homoeopathicity of arsenic 
to this condition. — Calcarea carbonic a frequently does sur- 
prisingly good work by its profound action as a corrector of 
malnutrition; its well-known constitutional indications must 
be present. The choreic movements rarery are violent, but the 
case is tedious in the extreme. — Sulphur is similarly useful 
when there is a scrofulous taint, especially when the child is 
thin, badly nourished, has dr\ r , unhealthy skin, and suffers from 
chronic constipation. 

Other remedies to be consulted are: Gelsemium. Great mus- 
cular weakness; paresis. — Causticum. Paralytic tendency; 
aphonia; heavy, mumbling speech; weakness of the bladder; 
chorea affecting the e3'e-ball and the right side. — Tarentula. 
Spinal irritability; nocturnal chorea; choreic movements of the 
extremities; the movements are violent and jerky. — Physos- 
tigma. Cardiac chorea; spinal irritation, tetanic rigidity of 
muscles. — Zincum. Chorea with incessant movements; mostly 
twitching, especially during sleep, the feet particularly affected. 
(T. F. Allen.) Anaemia. — Nux vomica. Characteristic gastric 
symptoms; spinal irritation. — Cina and Spigelia. Irritation 
from intestinal worms. — Rhus. Rheumatic cases, with mus- 
cular fatigue and soreness. — Pulsatilla. In chlorotic and 
hysterical young girls, with characteristic mental symptoms 
and menstrual disturbances. 

other affections characterized by choreic 
movements. 

Reflex chorea consists of local or general choreic movements 
which are due to peripheral irritation, usually the presence of 
intestinal worms, neuromatous tumors, decayed teeth, nasal 
deformities, rarety phimosis, adherent prepuce or clitoris, or 
disease of the orifices of the body. Reflex chorea is not as 
common as has been thought. In all cases a predisposition to 
the disease exists, stimulated into active manifestation by the 
immediate, exciting cause. The symptoms are those of St. 
Vitus's Dance. Removal of the cause, aided by the adminis- 
tration of the symptomatically indicated remedy, is followed 
by rapid improvement and a cure. Here also belongs the 
chorea of pregnancy, of which the pregnant state itself, the con- 
dition of the blood and the special demands made upon the 



GENERAL AND FUNCTIONAL DISEASES. 481 

vital forces of the mother are the exciting causes. The serious- 
ness of this form of chorea arises largely from loss of sleep and 
the extreme physical exhaustion resulting from it. Attacks of 
mania may occur. In this form energetic measures are de- 
manded. Abundant feeding is absolutely necessary and stimu- 
lants may be freely used. To afford sleep, chloral and opium 
may become indispensable. Since the life of both mother and 
child are endangered, it is often necessary to save the mother at 
the sacrifice of the foetus; when this necessity presents itself, 
measures to produce an abortion should not be deferred too 
long. 

Chorea major or pandemic chorea is simply an hysterical 
state with choreic movements and wild excitement of a relig- 
ious character. Epidemics of this sort were common in the 
middle ages, and have occurred among the early settlers of 
Kentucky. In the parlance of the common people the term "St. 
Yitus's Dance" refers to this affection rather than to acute 
chorea. 

Electrical chorea (Dubini's disease) has been observed in 
Lombardy and some parts of Italy. It derives its name from 
the peculiar contractions of the affected parts, which closely 
resemble the contractions produced by the interrupted galvanic 
current. The choreic movements usually begin in one arm, ex- 
tend to the leg of the same side, then invade the other side of 
the body. Exhaustion and atrophy of the muscles are followed 
by paralysis and death. This form is very rare; nothing posi- 
tive is known of its aetiology (malaria?) or pathology. 

Habit spasms are seen in rapidly growing children of neurotic 
tendency, oftenest between the seventh and fourteenth year of 
age. There are odd, peculiar movements, as the periodical lift- 
ing of one eye-brow, or a shrug of the shoulder, or a grimace, 
or protrusion of the jaw, or a short inspiratory sniff. It is in 
reality a habit, the result of an inexplainable dominating im- 
pulse, and shows itself particularly when the child is laboring 
under excitement of some sort. The affection is usualty tran- 
sient, passing away sooner or later, and deserves no notice save 
as it should call attention to an unpleasant habit of the child 
and to the possible danger of more serious trouble. It is on 
this account that a careful examination of the child is justified. 

Tic convulsif or Gilles de la Tourette' s disease. This affection 
31 



482 DISEASES OF THE NERVOUS SYSTEM. 

is characterized by choreic movements, almost explosive, in- 
volving usually the facial and brachial muscles, but sometimes 
general. With it are produced explosive sounds, sometimes 
resembling a bark or cr}\ The patient mimics words (echola- 
lia), repeating them over and over again, and in some cases 
actions (echokinesis); or she may get into the habit of using 
profane and obscene words (coprolalia); these nearly always 
occur when the involuntary movements are made. In some in- 
stances a monomania develops. Thus Osier relates the case of 
a young girl in whom the choreic movements were very slight, 
but who had become an arithmomaniac. Every act of hers 
was preceded by counting a certain number of figures. For 
instance, before going to bed, or taking a glass of water, or 
combing her hair, she had to count up to a certain number. 
Such cases occur in strongly neurotic families, in children or 
young persons, and are not readily amenable to treatment. 

Saltatoric spasm, described by Bamberger, consists of violent 
contractions in the muscles of the legs when attempting to 
stand, producing a jumping, springing motion. It occurs in 
neurotic persons and is transient, though occasionally it may 
persist for 3'ears. The terms mvriachit, latah, and other pro- 
vincial names, are applied to a condition of which the so-called 
"jumping Frenchmen" of Maine and Canada are fair types. 
The patient jumps violently and utters a loud cry when startled 
by the slightest sound or touch; there is a tendency to mimic 
words or actions; sometimes any command given is unhesitat- 
ingly obeyed. The affection prevails in certain families, and 
allied forms have been observed in Russia and Java. 

Huntington's chorea. Chronic Chorea. — This affection con- 
sists of irregular choreic movements, beginning in the hands, 
gradually becoming general; they are of a disorderly, irregular, 
incoordinate character, differing from the abrupt energetic 
movements of acute chorea. It is frequently, but not always, 
hereditary, usually sets in between the thirtieth and fortieth 
year, and is accompanied with mental enfeeblement drifting 
into dementia. The hesitating, disorderly character of the 
movements is striking. In the face it gives rise to seemingly 
labored, involuntary grimaces; the speech is slow, indistinct, 
the walk unsteady and swaying, like that of a drunken per- 
son. Since Huntington first described the affection, other cases 



GENERAL AND FUNCTIONAL DISEASES. 483 

have been observed in this country. The disease seems to be 
the result of organic changes in the brain which are not yet 
understood; it is incurable and of very long duration. 

Rhythmic chorea is largely hysterical in character. It may 
affect any part of the body, limbs, face, tongue, larynx, abdom- 
inal muscles (salaam convulsions), muscles of respiration, etc. 
The choreic movements not infrequently slowly assume the de- 
liberate, purposive character of hysteria. 

TETANY (Tetanilla). 

A nervous affection of unknown pathology, characterized by 
tonic spasms in certain groups of muscles, nearly always bilat- 
eral, usually occurring in the extremities, without loss of con- 
sciousness. 

^Etiology. — Tetany is a disease of childhood and early adult 
life, slightly more frequent in males than in females, and usually 
associated with an inherited neurotic tendency. It is rare on 
the American Continent. The greater number of cases are seen 
in connection with a low state of vitality. Thus, in children 
the process of dentition, or rickets, or chronic gastro-intestinal 
disease favor tetany, while in adults prolonged lactation, fevers, 
etc., are among the important causes. Tetany has followed 
removal of the thyroid gland and has occurred in connection 
with dilatation of the stomach, especially after washing out 
the stomach. An acute, epidemic form (rheumatic tetany), of 
two or three weeks' duration and favorable termination, has 
been observed in Europe. 

Symptoms. — The prodromal stage, occupying from several 
days to a week, consists of some pain in the extremities, -with 
coldness and formication, sometimes vertigo, ringing in the 
ears, nausea, and sense of great fatigue. The paroxysms may 
appear at any time; they usually first attack the arms and 
fingers, and may be confined to them. If in the arm, the flexors 
of the fingers and wrist are contracted, the hand assuming the 
shape in which the obstetrician passes it into the vagina 
(Trousseau); if all the muscles of the arm and shoulder are in- 
volved in the spasm, the forearms are flexed and crossed in 
front. If the legs are affected, the feet are distorted, usually 
violently extended, the toes pointing downward, the big toe 
drawn under the other toes, and the thighs strongly adducted. 



484 DISEASES OF THE NERVOUS SYSTEM. 

The muscles of the trunk are rarely involved; if so, there is 
oposthotonos or pleurosthotonos, or the spine may be bent 
forward. Cyanosis and a sensation of being choked results 
from involvement of the muscles of the neck, and serious re- 
spiratory embarrassment from spasm of the respiratory mus- 
cles; the latter, however, is observed only in exceptionally 
severe cases. The affected muscles are hard, stand out promi- 
nently, and are sensitive to pressure. During the spasms 
fibrillary movements have been observed. It is said that the 
spasms ma}- be overcome by the force of the will, but that they 
return as soon as the effort of the will ceases. The duration of 
the attack varies, lasting from a few minutes to several days, 
and even months or years, with a strong tendency to recur- 
rence at longer or shorter intervals. The course of the disease 
is comparatively painless, but there is often tingling, coldness, 
and moderate neuralgia. 

There is increase of electrical irritability of the affected motor 
nerve (Erb) and increased excitability of the sensory nerves, 
with paresthesia in the region of its distribution from slight 
pressure (Hofman). Trousseau points out that any time dur- 
ing tetany obstruction of the circulation by compressing the 
affected parts in the direction of their principal nerve trunks or 
blood vessels will bring on an attack within a few^ minutes, 
which disappears soon after the pressure has been removed. 
Chovesteck has shown an increase in the mechanical excita- 
bility of the motor nerves; a slight tap in the course of the 
nerve will cause violent contraction in the parts under its con- 
trol. 

Diagnosis. — Tetany may usually be recognized without dif- 
ficult}^. It bears some resemblance to hysteria, but in hysteria 
the contractions are unilateral, there is no increase of electrical 
irritability, pressure upon the parts (Trousseau's symptom) 
does not cause spasm, the patient is usually of the female sex, 
and there is the history of hysteria. Tetanus presents a pic- 
ture of intense tonic rigidity, lockjaw, and a history of trauma- 
tism. 

Treatment consists of measures which will improve the gen- 
eral health of the patient and of the exhibition of the symp- 
tomatieally indicated remedy. The patient must, if possible, 
be placed amidst favorable hygienic surroundings, be fed abun- 



GENERAL AND FUNCTIONAL DISEASES. 485 

dantly on wholesome, nourishing food, and be directed to take 
systematic moderate exercise. Cold sponge-baths, massage, 
and cold applications to the spine are helpful. General faradi- 
zation has yielded good results. The thyroid-extract treat- 
ment has been recommended, if other means fail. 

PARALYSIS AGITAIMS. 

Paralysis agitans (Parkinson's disease, Shaking Palsy) is a 
chronic affection of the nervous system, of unknown pathology, 
usually seen in persons of advanced years, associated with 
muscular weakness, tremors, and rigidity. 

./Etiology. — This disease occurs oftenest between fifty and 
sixty, rarely before forty, years of age. Heredity is not import- 
ant, save as an inherited neurotic tendency may predispose to 
it. Men have it oftener than women. It is known to have fol- 
lowed powerful emotional disturbances, bodily injury, espe- 
cially when received during a time of emotional excitement, 
prolonged worry, and exposure to severe cold. Alcohol, 
syphilis and venereal excesses do not cause it. The majority 
of cases develop without apparent cause, leaving the impres- 
sion of a condition of premature senility. It is not an uncom- 
mon affection; very exceptionally cases have been observed in 
early manhood. 

Symptoms. — In rare cases the onset is sudden, following 
some powerful emotional agitation, but usually the approach 
of the disease is insidious and gradual. The first thing noticed 
are tremors in the hand or foot, usually in the fingers and 
hand; if in the hand, they after a time extend to the leg on the 
same side of the body, and then to hand and leg of the opposite 
side. The tremors may be constant or intermittent, or marked 
only during rest after some exertion; at first they may be con- 
trolled by an effort of will, and are suspended by voluntary 
movements. As they extend from limb to limb, this controlling 
influence of the will is lost, and they finally persist during both 
action and repose. The forearm is usually slightly flexed, as is 
also the hand, while the fingers are in the position which they 
assume when holding a pen or as though rolling a pin between 
the forefinger and thumb. In the leg, the ankle especially is 
affected. Later, and more rarely, the head may begin to 



486 DISEASES OF THE NERVOUS SYSTEM. 

shake, usually vertically. There is no interference with eating 
and swallowing, but dribbling of saliva may result from loss 
of power in the lips and from the attitude of the head, which 
is bent forward; the face eventually assumes a fixed, sad ex- 
pression, and the voice grows monotonous, sometimes piping; 
speech often at first is slow and labored, but becomes rapid 
after the sentence is well under way. The tremors are short 
and rapid, about five oscillations per second; they are increased 
b3^ excitement. Great muscular weakness develops after a time, 
with, often, severe aching in the affected muscles, as though 
from excessive weariness. The attitude and gait of the patient 
are peculiar. He stands with the body bent forward, the arms 
flexed and away from the body, the hands usually turned toward 
the ulnar side, with contractions at the elbows, knees, and ankles 
in the late stage of the disease. He arises from the chair with 
the body, especially the head, bent far forward, rendering the 
act difficult and awkward. The gait is characterized b\' this 
same peculiar forward inclination of the head and trunk; at 
first the movement is deliberate and slow, but there is progres- 
sive increase in the rapidity of the gait (festination) , as though 
from a forward displacement of the centre cf gravity, the pa- 
tient, seemingly to keep from falling, walking faster and 
faster, and finally breaking into a run, until he actually falls or 
manages to save himself by grasping some stationary object. 
In some cases there is retropulsion or walking backward, with 
tendency to fall backward. The typical attitude and gait de- 
pend upon rigidity and fixation of the parts, which in the early 
stage and in the less developed form gives rise to slowness and 
clumsiness of voluntary movements. Frequently the patient 
in the advanced stage complains of dull aching in the muscles, 
as though from exhaustion following overexertion, but there 
is very little real pain. A sensation of great heat is not un- 
usual, and there is occasionally habitual sweating. The sur- 
face temperature may be materially raised. The urine is defi- 
cient in sulphates and, according to some observers, notably 
Cheron, rich in phosphates. 

The course of the disease is very slow and progressively 
downward, without hope of permanent improvement or cure. 
After years, enfeeblement of the intellect occurs in the majority 
of cases, with innutrition, great emaciation and bodily ex- 



GENERAL AND FUNCTIONAL DISEASES. 487 

haustion, the patient, in the absence of some fatal intercurrent 
disease, dying from asthenia. 

The diagnosis is easy, save perhaps in the exceptional cases 
without tremors; but even in these the fixed "masked" face 
will establish the nature of the affection. Senile tremors might 
be mistaken for the tremors of shaking palsy, but in these the 
head shakes harder and at a slower movement, and there is 
much trembling of the tongue and lower jaw. 

Treatment. — This consists chiefly of measures which insure 
quiet and prevent every avoidable exertion of body and mind. 
The question of using nerve sedatives when the disease is well 
advanced is a practical one, and should be answered promptly 
in the negative, exceptions being made only in extreme cases 
and after a faithful trial of every other means; in such excep- 
tional cases it may be well to follow Wood's plan of giving one 
dose of hydrobromate of hyoscine at night. Hot baths usually 
have a soothing effect. Electricity is used in various forms, the 
authorities being divided as to its merits and the methods of 
applying it. I am prejudiced in favor of daily faradization of 
the spine, using a moderate current for ten or twelve minutes. 

The actual value of medication here has not yet been deter- 
mined. A careful examination of the clinical experience re- 
corded by the entire profession leaves the impression that noth- 
ing positive has been accomplished by the administration of 
medicines. Gelsempjm, Physostigma, Baryta, Plumbum, 
Mercury, Rhus toxicodendron, Phosphoric acid, Phos- 
phorus and Picric acid should be studied. 

TRAUMATIC NEUROSIS. 

A neurasthenic state caused by injury or shock. It is also 
called spinal neurasthenia, spinal concussion, railway spine (or 
railway brain). 

Etiology. — The most frequent causes are accidents and 
wrecks on railroads, steamboats, violent concussions or 
shocks. Severe moral shock has the same effect; a man may be 
the innocent cause or the witness of a frightful accident, and, 
though not necessarily much affected at the time, may soon 
after develop a profound neurasthenia, usually with predomi- 
nance of the brain symptoms. 



488 DISEASES OF THE NERVOUS SYSTEM. 

Symptoms. — The neurotic condition may develop at once, or 
several days or a week may elapse before the subject is con- 
scious of having suffered harm. Thus a train may be wrecked; 
a passenger who has escaped injury works heroically at the 
rescue of others, appearing unusually energetic and well; he re- 
turns to his home and business, evidently none the worse for 
his experience; but after a few days he is taken ill, remains in 
broken health for a long time, and eventually may be wholly 
disqualified for any kind of useful activity. The prodromal 
symptoms are those of general indisposition and physical 
weakness; these are followed by mental disquiet, irritability, 
failure of brain power, despondenc\% headache, often with ring- 
ing in the ears, insomnia and the entire train of symptoms de- 
scribed under neurasthenia. There are frequently hysterical 
symptoms of remarkable severity, closely resembling petit mal, 
even to loss of consciousness, while in other and rare cases 
there may be delirium and even mania; sometimes diabetes has 
occurred. These cases may partake of any one of the many ec- 
centricities of neurasthenia or hysteria. 

Exceptionally serious organic disease of the brain or of the 
spine ma} 7 result from a concussion which gave no external evi- 
dence of an injury received. In such cases the symptoms at 
first may be those of profound hysteria (sensory disturbances, 
paralysis, especially monoplegia, contractures without atro- 
phy), but eventually symptoms will develop which indicate 
profound organic lesions (atrophy of the optic nerve, tremors, 
paresis, exaggerated reflexes, etc.). Our knowledge of the exact 
nature of the organic lesions, as the result of concussion, is 
very limited. Cases have been recorded of chronic pachymenin- 
gitis, of degeneration in the pyramidal tracts, of punctiform 
haemorrhages in the brain or cord; extensive arterio-sclerosis of 
the vessels of the brain and cord has been observed in several 
cases, with degenerative changes in the brain substances. In 
all these, symptoms of neurasthenia and hysteria were pro- 
nounced in the early stage. 

The diagnosis is of particular interest in view of the medico- 
legal aspect of these cases, usually connected with suits for 
damages against large corporations. The plaintiff is natur- 
ally, often justly, suspected of malingering or of wilfully exag- 
gerating the severity of the harm received, and medical testi- 



GENERAL AND FUNCTIONAL DISEASES. 489 

mony must decide the extent of the mischief actually done. It is 
to be remembered that the hysterical symptoms, though often 
in appearance the most serious, are in reality comparatively 
trivial, while the neurasthenic condition is much more grave. 
Especial pains must be taken to recognize indications of organic 
lesion of the brain or cord, since these are sure to increase con- 
tinuously, with the certainty^ of prolonged and even complete 
disability from them. It must also be borne in mind that in 
the purely neurasthenic type the course of the affection is very 
slow, and that, while life is not endangered, the patient may be 
for years, and possibly for life, unfitted to hold a position in- 
volving responsibility or close application to work. 

Treatment is that of neurasthenia, the Weir Mitchell treat- 
ment, i. e., absolute rest of mind and body for a long time, 
being indispensable to a permanent recovery. There is a strong 
tendency to relapse from any premature effort to assume the 
duties of business life. 



CAISSON DISEASE OR DIVER'S PARALYSIS. 

An affection found among divers and workers in caissons > 
produced by a too sudden return to the normal atmospheric 
pressure after prolonged subjection to a highly compressed at- 
mosphere, which must always exceed the pressure of three at- 
mospheres. Practically nothing positive is known of its pa- 
thology. 

Symptoms. — Usually the symptoms begin within a short 
time, from half an hour to two hours, sometimes immediately, 
after return to the surface. In the mild form, there are intense 
pains about the knees, legs, and hands, occurring in paroxysms, 
sometimes with painful retching, vomiting and colic; dizziness 
and headache are often present. In the severer form this is 
soon followed by loss of motor power and sensation in the 
legs, either a paraplegia or a paralysis involving the trunk and 
arms; the excruciating pains continue even though anaesthesia 
may be complete. A cerebral type has been described, with in- 
tense pain in the head, dizziness, double vision, incoherent 
speech, delirium and loss of consciousness. In extreme cases the 
patient appears as though smitten with apoplexy and may 
rapidly drift into coma and death. 



490 DISEASES OF THE NERVOUS SYSTEM. 

Recovery may be rapid; even severe paraplegia may pass off 
in a few da^^s, while in other cases it ma}' persist for months. 
In a large number of cases recovery is tedious and not always 
complete. Death occurs early from apoplexy, late from para- 
\ytic bedsores and cystitis. 

Treatment. — Preventive treatment consists of care in grad- 
ually getting accustomed to work under high atmospheric 
pressure and in taking an abundance of time in returning to 
the surface; it is stated that at least five minutes should be al- 
lowed for each additional atmosphere of pressure; upon coming 
to the surface, the men should always rest for a short time. 
Immediate return to the caisson has been advised on the ap- 
pearance of the first symptoms of the disease. During the at- 
tack inhalations of oxygen and the use of compressed air are 
recommended. For the relief of the intense pain, applications 
of hot water, rapidly renewed, are useful; morphia may be de- 
manded. Other treatment is that of myelitis. See also "para- 
plegia." 

OCCUPATION NECROSIS. 

An affection consisting of involuntary spasmodic contrac- 
tions of certain groups of muscles, interfering with or prevent- 
ing the performance of the intended acts, resulting from the 
excessive use of such muscles in the pursuit of various callings. 
This condition is found in writers, pianists, violinists, tailors, 
telegraph operators, type-writers, professional dancers (mus- 
cles of the calves of the legs), and many others. That the af- 
fection is of central origin is indicated lyy the fact that in per- 
sons who have learned to use the left hand in writing, because 
of writer's cramp in the right, the left nearly always in a short 
time becomes involved in the same difficulty; furthermore, 
writer's cramp is in many cases the first indication of a neu- 
rasthenic state and may be brought on by anxiety and worry. 
Men of a nervous temperament are more frequently affected 
than women engaged in the same occupation. 

Writer's Cramp is especially common in persons who use the 
little finger or the wrist as the pivot, and rarely, according to 
Gowers, affects those who write from the middle of the forearm 
or from the elbow or even shoulder. Copyists who work con- 



GENERAL AND FUNCTIONAL DISEASES. 491 

tinuously and at a high rate of speed suffer from it oftener than 
persons who can give the muscles occasional rest. 

Symptoms. — The onset is usually gradual. There is con- 
scious difficulty in holding the pen and interference with accus- 
tomed freedom in executing the necessary movements. A sense 
of fatigue in the fingers and often in the forearm, with feeling 
of rigidity in the muscles, is frequent, demanding a certain 
amount of effort to keep the pen moving. Sometimes formica- 
tion and numbness are felt. As the affection increases, pain in 
the arm is common, sometimes consisting merely of a painful 
sense of fatigue, at others neuralgic in character; this pain 
may gradually extend upward, and may be very severe in a 
spot between the shoulder-blades. The sense of stiffness or 
tonic rigidity in the muscles is marked, and may amount to 
positive resistance when trying to grasp the pen. Spasmodic 
contractions are frequent. At first they merely interfere with 
the regularity and clearness of the writing, producing irregular 
strokes toward one side or the other, up or down, but after a 
time they become more violent and jerk the pen away from the 
paper, or hold it as in a vise by sudden flexion of the fingers, or 
drop it unceremoniously by sudden extension of the fingers. 
These spasmodic contractions in aggravated cases may involve 
the entire arm. More rarely tremors occur, especially in the 
forefingers, but also, in severe cases, affecting the forearm and 
arm, so completely disfiguring the writing as to render it 
wholly illegible. 

Exceptionally there is subacute neuritis with numbness and 
tingling in the fingers and pain over the nerves. Hyperesthesia 
is sometimes present. Rarely flushing of the parts, with heat 
and venous engorgement, has been observed. 

The diagnosis is easy, but care must be had to differentiate 
from cerebro-spinal disease (as progressive muscular atrophy). 

The prognosis is not favorable, since resumption of the work 
usually brings on a relapse. 

The treatment consists of absolute cessation of all attempts 
to use the pen. Massage, intelligently and perseveringly em- 
ployed, is of the greatest benefit. The galvanic current is use- 
ful. Wood directs that a small positive pole be placed over the 
nerve trunks in the groove of the inside upper arm, letting the 



492 DISEASES OF THE NERVOUS SYSTEM. 

hand rest on a large sponge electrode connected with the nega- 
tive pole, a light current being used. 

Persons who are obliged to write much should use a large 
penholder and a blunt-pointed pen, cultivating a free round 
hand. The first appearance of symptoms indicating writer's 
cramp should lead to the use of the type-writer. 

miGR4INE (Hemicrania; Megrim; Sick Headache. 

A paroxysmal affection characterized by severe headache, 
nearly always unilateral, usually associated with sensory dis- 
turbances. 

/Etiology. — The chief predisposing cause is an inherited neu- 
rotic tendency. The affection is sometimes handed down 
through several generations. A gouty and rheumatic bias has 
been observed. Many cases are due to reflex irritation, as from 
eye-strain, uterine and menstrual disorders in adults, and from 
affections of the nostrils and adenoid growths of the pharynx 
in children. Exciting causes are: powerful emotions, mental 
excitement, great bodily fatigue, as a long journey on the cars 
(eye-strain?), and indigestion, usually from errors in diet. Sick 
headache occurs much oftener in women than in men. It 
usually begins early in life, from the fifth to the tenth year, a 
first attack rarely occurring after the thirtieth year; it may 
recur with distressing regularity throughout life. 

Symptoms. — The premonitory symptoms are chilliness, lan- 
guor and mental confusion, excitement or depression. In 
many cases these are striking and remind one strongly of the 
aura of epilepsy. A majority of them are referred to the sense 
of vision. There may be transient hemianopia or scotoma; 
others present hippus, alternating contraction or dilatation of 
the pupil, on the affected side; still others see balls of fire or the 
so-called fortification-lines, often brilliantly colored. Vision is 
nearly always blurred. More rarely there are hallucinations of 
sight, as animals about the room. Hallucinations of smell (of 
osmic acid), of hearing (sounds as though a marine shell were 
placed to the ear) and of taste (sour, metallic taste) are less 
frequent. Again, numbness and tingling of tongue, face, and 
hands have been described, and very rarely transient motor and 
sensory aphasia. The headache, which soon follows, begins in 
and emanates from a clearly defined spot, near the supra-orbi- 



GENERAL AND FUNCTIONAL DISEASES. 493 

tal foramen, more rarely in the eye-ball. It is cumulative, of a 
boring character, of intense severity and expansive, extending 
sometimes very rapidly, to the entire affected side of the head, 
into the neck, and often into the arms; occasionally it occupies 
the occiput. The suffering is intense, the patient lying utterly 
prostrated, unable to raise the head from the pillow, and usually 
enduring tortures from the slightest noise and light. Often 
the headache is accompanied with nausea, retching and vomit- 
ing, first of the contents of the stomach, then of bile and mucus. 
In many cases, when the stomach is full, vomiting affords relief, 
and it is not unusual to have an attack pass off in this manner, 
the patient, exhausted from the effort, falling asleep, and wak- 
ing feeling well; in others the paroxysm comes to a close with 
copious emissions of limpid, colorless urine. 

There is usually pallor of the face, followed by flushing of 
the affected side, with slow pulse. There may be stiffness and 
hardness of the temporal artery on the affected side, like that 
of arterio-sclerosis, the existence of which has, in fact, been de- 
monstrated (Thoma). 

The duration of an attack is rarely less than a day; if severe, 
it may last two or three days. The paroxysms have a ten- 
dency to recur regularly at stated intervals or at any time 
when brought on by the special conditions which in the indi- 
vidual affected act as exciting cause. This may continue for 
many years, not infrequently for life. Often, however, the at- 
tacks cease at the climacteric period in women and at about 
fifty years of age in men. 

Nothing positive is known of the pathology of migraine. 
Gowers calls it a "nerve-storm," and Osier, in carrying out this 
generally accepted figure of speech, suggests that the attack it- 
self in that case is the "sensory equivalent of a true epileptic 
attack." This, indeed, seems to be the case, and not exception- 
ally migraine may in the same individual alternate with epi- 
lepsy, as with some other neurosis. Others teach that the 
early symptoms of migraine are due to constriction, the later 
symptoms to dilatation, of the blood-vessels. 

Treatment.— Removal of the cause, whenever possible, should 
receive the first care. Hence the necessity of looking for errors 
of refraction and, in children, for such abnormal conditions of 
the nostrils and pharynx as may be at fault; their correction 



494 DISEASES OF THE NERVOUS SYSTEM. 

may cure migraine. In both adults and children any measures 
which restrict the neurotic tendency by building up the system 
should be promptly adopted. Children especially may be saved 
much suffering if wisdom is exercised in the regulation of their 
every-day life, if they are not allowed to indulge largely in 
sweets and pastries, but are furnished plain, sensible, whole- 
some food, and are made to live an active life in the open air 
and to have long hours of sleep. To avoid overtaxing the eyes, 
children should not be permitted to pore too long over school 
books or stories. It is evidently a matter of common sense to 
avoid known causes of hemicrania. Adults usually are well 
aware of what is likely to bring on a paroxysm in their own 
case, and will not bring upon themselves severe suffering by 
some deliberate act on their part; in children, also, observation 
and experience will soon show what they must avoid. 

During a paroxysm the patient needs, and will of his own ac- 
cord demand, perfect quiet and, probably, rest in bed. Some- 
times relief may be had by tightly bandaging the head or by 
drinking a cup of very hot strong black coffee. Some patients 
find alleviation from 10 to 20 drops of chloroform. The ho- 
moeopathically indicated remedy often accomplishes a perma- 
nent cure and rarely fails to ameliorate the intensity of a par- 
oxysm within a reasonable length of time. 

Argentum nitricum. Headaches usually begin in the morn- 
ing. They are deep-seated, boring, screwing, pressive, in the 
temples, and extend into the face. Accompanied with dim- 
ness of vision, inclination to reel sideways, ringing in the ears, 
chilliness, thick white coating of the tongue, flatulent disten- 
sion of the stomach, nausea and vomiting. Relief is obtained 
from bandaging the head tightly; from eating; from taking a 
glass of wine. Sometimes the pain seems pressing from within 
outward, as though the bones in the aching region were pressed 
apart. When the gastric symptoms are at their worst, there 
is excessive faintness, trembling of the whole body, profuse 
cold sweat, followed by vomiting and, at least temporary, re- 
lief. — Iris. One of the best remedies when the attacks occur at 
short intervals and are connected with severe gastric symp- 
toms. The pain is oftenest in the right side, over the eye, bor- 
ing, sometimes hammering or clawing. There is much nausea 
and repeated vomiting, often of sour, bitter, watery substance, 



GENERAL AND FUNCTIONAL DISEASES. 495 

sometimes of clear bile. The patient is "bilious" a good por- 
tion of the time and is habitually constipated. Blurred vision. 
— Ignatia. Headache from emotional, depressing influences, 
in character resembling clavus hystericus. Sometimes occi- 
pital; better from inclining the head forward, from stooping. 
Hysterical disposition. — Sanguinaria. Attack begins on the 
right side, in the forehead and vertex, or in the occiput, and 
from there extends to the right supra-orbital region. There is 
frequently a copious discharge of water from the right eye 
while the attack lasts. Relief from sleep; the paroxysm passes 
away with free flow of limpid urine. — Glonoine. Strong pul- 
sations in the head; every beat of the heart feels like the blow 
of a hammer in the painful region of the head. Surging, wave- 
like sensation in the brain; crushing pain. The face looks pur- 
plish and bloated; he is fairly crazed with the intensity of the 
pain. The head feels enlarged. Ringing in the ears; fluttering 
and violent beating of the heart. Somewhat better from steady, 
hard pressure.— Belladonna (Atropine). Occasionally useful 
in young, plethoric people, with right-sided hemicrania and 
symptoms of active cerebral congestion which do not, how- 
ever, reach the intensity which calls for Glonoine. "Throbbing 
of carotid arteries." Sometimes great pallor of the face. 
Worse from lying down, from motion, from a jar, from touch; 
better from pressure and from bending the head backward. — 
Nux vomica. The pain is of a neuralgic type, involving the eye 
and face, and accompanied with numbness in the affected 
parts, watering of eyes and nose, and great sensitiveness of the 
eyes to light. Pressive, dull boring pain over the left eye. 
With vertigo, characteristic gastric symptoms and other gen- 
eral indications. Pain in the occiput, heavy, grinding; almost 
drives him crazy. — Spigelia. Neuralgic headache, generally be- 
ginning at one point and radiating in different directions; 
pains burning, jerking and tearing, sometimes ending with 
vomiting, sometimes beginning in the morning and ending in 
the evening, at times a feeling as if the head were opening. (T. 
F. Allen.) Worse from stooping, motion, concussion, noise and 
during stool. Tendency to recur at regular hours.— Cannabis 
Indica. Sensation as if the head were opening and shutting. 
Pain agonizing. Great excitement; delirium; unconsciousness. 
Excessive prostration. Face pale, head cool. Very strongly rec- 



496 DISEASES OF THE NERVOUS SYSTEM. 

ommended 03^ Hale. Given by the dominant school as a favor- 
ite routine prescription in doses sufficiently large to merely fall 
short of producing physiological effects.— Stannum. Patient 
gentle, hypochondriac, tearful. Pains get worse and better 
gradually; cramp-like, as if constricted by a band; as if forced 
asunder. Consult also Arsenicum, Aurum met., Cactus, Cof- 
fea, gelsemium, phosphorus, pulsatilla, sepia, sllica, 
Sulphur, Thuja, Veratrum, Zincum. 

For the purpose of obtaining immediate relief, the coal-tar 
preparations are commonly used by practitioners. I am pre- 
judiced against them on account of their depressing influence 
and lack of curative power. Phenacetine is usually given in 
doses of ten grains. Bartlett recommends a mixture of acetan- 
ilide and caffeine in proportion of three and a-half grains of the 
former to one-half grain of the latter, giving from four to 
eight grains of the mixture as the initial dose; he repeats in 
an hour, if the drug is borne well. 

NEURALGIA. 

A painful affection of the nerves, felt in the course or in the 
distribution of one or more special nerve trunks or branches, 
occurring in paroxysms of intense pain, and resulting from dis- 
turbance at the central or peripheral extremities of the nerves 
or from a neuritis in their course. 

Etiology.— Neuralgia is an affection of middle life, more fre- 
quent in women than in men, and rare in children. It prevails 
in persons of neuropathic predisposition, and here, as in other 
neuroses, debility and anaemia are commonly associated with 
it. Cold, i. e., draughts, wind and wet, are responsible for 
many cases. It sometimes occurs in the early stage of certain 
acute fevers (typhoid, small-pox) and may be an expression of 
the malarial cachexia. 

Neuralgia is also a feature of poisoning with lead, copper, 
mercury, sometimes alcohol and nicotine, and may complicate 
gout, rheumatism and diabetes. Reflex neuralgia, so-called, 
may arise from irritation without the nerves, as in the sexual 
organs or, in case of neuralgia of the fifth nerve, from caries of 
the teeth. 

Symptoms. — Usually the paroxysm of pain is preceded by 
coldness, uneasiness, numbness and tingling of the part. The 



GENERAL AND FUNCTIONAL DISEASES. 497 

pain is very severe and boring, darting or stabbing in charac- 
ter; it may be continuous; more often periods of acute exacer- 
bation are noticed. It commonly follows the course of the af- 
fected nerve, but may radiate into neighboring parts. There is 
usually hyperesthesia of the skin over the affected parts, with 
definite points which are very painful and sensitive to light 
pressure (Yalleix's points douloureux); these may sometimes 
be found during the interval between the paroxysms, and then 
aid in the diagnosis. There may be motor-irritation, but par- 
alysis is never present in uncomplicated cases. The face, espe- 
cially in the trigeminal form of neuralgia, is pale, sometimes 
red, hot and burning. Of trophic disturbances the most im- 
portant are herpes, urticaria, pigmentation of the skin, rarely 
falling out or whitening of the hair. Usually the general health 
and nutrition are not affected, but in particularly severe cases 
the suffering is so intense that the patient becomes emaciated 
and depressed; cases of mental aberration and suicide, as the 
result of the intolerable pain endured in incurable cases, are not 
infrequent. 

INDIVIDUAL FORMS OF NEURALGIA. 

Neuralgia of the Trigeminus. (Trifacial neuralgia, prosopal- 
gia; tic douloureux). One of the common and very important 
forms of neuralgia, due, in addition to general causes, to irrita- 
tion from caries of the teeth and to affection of the nasal and 
frontal cavities and of the middle ear. Disease of the cranial 
bones and periosteum, chronic malarial poisoning and, possibly, 
excessive use of the eyes may cause this affection. The par- 
oxysms are nearly always intense, sometimes unbearable; the 
pain is usually worst in the branch especially affected, but may 
involve all the branches of the trifacial and radiate into the 
occiput, neck and shoulders. Here, if long-continued, falling 
out and blanching of the hair, with other pronounced trophic 
changes, are comparatively frequent. In neuralgia of the 
ophthalmic branch the pain is supra-orbital or frontal. There 
is usually pain to pressure on the point of exit of the nerve at 
the supra-orbital foramen and at the point of entrance into the 
muscle; also pain, sometimes, at the occipital protuberance and 
in the upper cervical spine. The conjunctiva may be injected; 
copious lachrymation is not uncommon. Neuralgia of the 
32 



498 DISEASES OF THE NERVOUS SYSTEM. 

second branch (supra-maxillary neuralgia) presents a painful 
point where the nerve leaves the infra-orbital foramen; others 
may be detected on the zygoma and upper lip. The pain is 
worst along the upper teeth. In neuralgia of the third branch 
(infra-maxillary neuralgia) the chief painful point is at the 
mental foramen. The pain involves the ear, lower jaw, and 
teeth, rendering speaking and masticating painful. There may 
be copious salivation. 

The prognosis is good in recent cases of which the cause can 
be removed; in old chronic cases and in those where the cause 
is beyond reach the prognosis is not encouraging. 

Cervico-occipital neuralgia involves the posterior branches of 
the first four cervical nerves. Painful points are usually found 
about midway between the mastoid process and the first cervi- 
cal vertebra. It is either the result of a cold or caused by caries 
or a new growth. Pain is severe. The neuralgia is nearly 
always bilateral, though worse on one side than on the other. 
Falling-out of the hair is frequent. 

Cervico-brachial neuralgia involves the sensory nerves of 
the brachial plexus. The radial and ulnar nerves are those 
usually affected. The causes are wounds, contusions of the 
nerves, cicatrices, foreign bodies, rheumatism of joints. There 
may be an ascending neuritis, the result of crushing of the 
fingers, the neuralgia then involving a considerable part of the 
arm. Here amputation-neuralgia, from neuromata on the cut 
end of nerves, plays an important part. Other cases are due to 
pressure on the brachials from a tumor in the axilla or aneur- 
ism of the aorta. The pain is rarely localized, but follows the 
course of the nerve throughout its length. There may be pain- 
ful points over the brachial plexus, over the radial on the ex- 
ternal surface of the upper arm, over the ulnar at the elbow, 
over the median at the inner border of the biceps, and over the 
point where the cutaneous nerves emerge from the fasciae. The 
most important trophic disturbances are "glossy fingers," a 
shiny atrophic condition of the skin of the fingers, and some- 
times noticeable atrophy of the entire arm. 

Neuralgia of the phrenic nerve gives rise to pain in the lower 
thorax, on a line with the insertion of the diaphragm. Any 
sudden depression of the diaphragm (coughing or deep inspira- 
tion) is painful. It is a rare form, sometimes seen in pleurisy 
and pericarditis. 



GENERAL AND FUNCTIONAL DISEASES. 490 

Intercostal neuralgia may occur idiopathically in hysterical 
and anaemic persons, especially in women, or in connection 
with caries, aneurism, pleuritis, or disease of the cord (tabes 
dorsalis). Usually the intercostals from the fifth to the ninth 
are affected, and more often those on the left side. Painful 
points are formed, one near the vertebral column, one at the 
middle of the nerve, and one near the sternum or over the 
rectus abdominalis. The pain is constant and much aggra- 
vated from movement. Herpes zoster or zona is seen in severe 
cases, probably due to neuritis of one or more of the intercostal* 
nerves. The pain precedes the eruption, but the eruption may 
occur without pain. The neuralgia continues indefinitely after 
the eruption has disappeared, and may be so severe as to make 
life a burden. The "pearly" eruption of this condition was 
thought to be of trophic origin; Dubber's anatomical studies lead 
him to believe that they may arise from an extension of the in- 
flammation from the terminal nerve branches to the skin. 
Mastodynia (neuralgia of the mammary gland), which in 
reality belongs here, is a painful and obstinate form usually oc- 
curring in women, after the age of puberty. It appears to hold 
some relation to anaemia and hysteria, and is at times the re- 
sult of traumatism. There is severe continuous or paroxysmal 
pain in the breast, in which occasionally little nodules may be 
felt, suggesting the possibility of carcinoma. These cases fre- 
quently are very stubborn and resist treatment for a long time. 
Bandaging the breast and the local application of heat (warm 
packs) may give relief; not infrequently recourse must be had 
to surgical treatment, but without positive assurance of a cure 
even then. 
Lumbar neuralgia is comparatively rare. It is usually lo- 
' cated in the ilio-scrotal branch of the lumbar plexus, and is 
characterized by pain along the crest of the ilium, inguinal 
canal, spermatic cord, scrotum or labium majus. Sir Astley 
Cooper's "irritable testis" probably belongs here, an affection 
in which intense pain is felt in the spermatic cord and testicles, 
usually with extreme hyperaesthesia of the parts, not rarely 
calling for castration. 

Coccydinia consists of severe pain in the region of the coccyx. 
It occurs much oftener in women than in men, is exaggerated 
by sitting, walking, and at stool, and may necessitate amputa- 



500 DISEASES OF THE NERVOUS SYSTEM. 

tion of the coccyx, a measure which does not always afford re- 
lief. 

Sciatica (sciatic neuralgia) may be a functional neurosis or a 
neuritis of the sciatic nerve or of its cords of origin. It is pecu- 
liarly a disease of adult males. Exposure to cold and wet, 
with overexertion, are its most frequent causes. Often there is 
a histor} T of gout or rheumatism. It may be caused by com- 
pression of the nerves by tumors within the pelvis, lymphade- 
nomata, or the foetal head during labor. Long-continued pres- 
sure by sitting in an uncomfortable position sometimes causes 
sciatica. Lesions of the hip-joint may induce a secondary form 
of the affection. In the operation of stretching the nerve for 
the cure of sciatic neuralgia it has been found red and swollen, 
in a condition of neuritis. 

Symptoms. — The onset is usually gradual. There is pain in 
the posterior thigh, felt most in certain positions and made 
worse from exertion, often much aggravated from turning in 
bed. Some fever may be present. The pain soon increases, 
sometimes rapidly, and involves the whole leg, radiating over 
the entire area of the distribution of the nerve. The pain is 
variously described as gnawing, boring, aching, or darting and 
lancinating; it may be continuous, but often there are par- 
oxysms of intense aggravation which are almost unendurable. 
The patient suffers most at night. Exquisitely sensitive spots 
are readily found at the notch or in the middle of the thigh. 
Walking is difficult; the knee is bent; at every step the patient 
feels his way, resting the foot on the toes to keep at a minimum 
the tension on the nerve. In some cases there may be sensory 
disturbances, as paresthesia, hyperesthesia or moderate anaes- 
thesia. There may also be motor}' irritation, tremors, twitch- 
ing and clonic spasms. In one case recently under my observa- 
tion clonic spasms were of frequent occurrence, and at one time 
persevered for an hour and a half, causing most excruciating 
suffering. If the case is unusually tedious, wasting of muscles 
may occur, but there is no reaction of degeneration. Excep- 
tionally the neuritis may ascend and involve the spinal cord. 

The duration of sciatica varies. The disease is obstinate and 
may continue for weeks and months. One nerve may recover, 
and the neuralgia then appear in the other; or relapses may 
take place, the case dragging on indefinitely, rendering the sub- 
ject bed-ridden and helpless. 



GENERAL AND FUNCTIONAL DISEASES. 501 

The diagnosis usually is not difficult. Affections of the hip- 
joint have no tenderness in the course of the nerve, and there 
is pain on moving the joint or upon pressure in the region of 
the trochanter. It must not be forgotten that sciatic pain 
occurs in the early stage of tabes dorsalis. Proper steps must 
be taken to determine if the sciatica is secondary to some affec- 
tion of the pelvis or to disease of the spinal cord. 

Neuralgia of the Nerves of the Feet. — The following forms 
are distinguished: "Painful heeV which renders walking diffi- 
cult. Plantar neuralgia, with pain in the tips of the toes or 
ball of the great toe, with, often, numbness, tingling, hyperes- 
thesia, or sweating. It partakes of the nature of a neuritis, 
and occurs after typhoid fever and in caisson disease. Metatar- 
salgia affects the fourth metatarso-phalangeal articulation, 
usually of one foot only, is very painful, and nearly always de- 
mands an operation. It is thought to be the result of pinching 
the metatarsal nerve. 

The Treatment of Neuralgia — Certain general facts underlie 
the treatment of all forms of neuralgia. Whatever tends to 
remove possible causes, and by building up the general health 
may enable the patient to resist an inherited tendency to neu- 
ralgia, may be considered in the light of prophylactic measures. 
Even after attacks of neuralgia have occurred, it is of the 
greatest possible importance to carefully look after the general 
health of the patient, for increased vigor may of itself prevent 
a return of the affection. To this end due observance of all the 
laws of wise living must be exacted; the habits of the patient 
must be considered and corrected where necessary; a life in the 
open air, properly regulated gymnastics, sea-bathing or such 
bathing as may be available, and a change of climate, prefera- 
bly some attractive spot in a moderately elevated mountain- 
region, are of inestimable value and usually quite sufficient to 
cure light or recent cases. Causes of reflex irritation must be 
promptly removed. The removal of tumors, excision of cica- 
tricial tissue, or so small an operation as the extraction of a de- 
cayed tooth may yield the most satisfactory results. Consti- 
tutional diseases or taints must be corrected; gout, rheuma- 
tism, syphilis, anaemia, a neuropathic tendency, any of these 
modified or cured, will change the entire aspect of the case. 
Thus, the proper regulation of the diet of a gouty person will 



502 DISEASES OF THE NERVOUS SYSTEM. 

indirectly have a favorable effect upon the neuralgia from 
which he suffers. The value of rest, especially in cases where a 
considerable area is affected, cannot easily be overestimated. 
In the treatment of sciatica, for instance, confinement of the 
affected leg in a long, well-padded splint, gives to the limb a de- 
gree of comfort which it cannot have otherwise, and may ma- 
terially lessen the duration of the attack; in chronic cases it is 
almost indispensable. Warm baths and the continued use of 
hot poultices are very beneficial. When within reach, natural 
mud baths should be taken. They are found in nearly all parts 
of the country, and even a short residence at one of them may 
in a surprisingly short time produce quite startling results. I 
know patients who are chronic sufferers from neuralgia who, 
by occasional resort to mud-baths, manage to get along very 
comfortably. 

There is a strong temptation in the treatment of these cases 
to resort to the use of opium, and it cannot be denied that at 
times the intense suffering of the patient justifies its use. All 
authorities, however, without regard to special therapeutic 
preferences, insist upon the danger which in all these cases at- 
tends the use of morphia. It requires more good sense and 
courage than most patients possess to bear severe pain rather 
than run the risk of permanent drug effects; hence the physician 
must be both judicious and firm. If the use of morphine be- 
comes unavoidable, the physician must administer it himself 
and must never allow the drug to be within the reach of the 
patient so he can take it when he pleases. 

Alcoholic stimulants at times seem beneficial; but they also 
must be used cautiously; in some cases their immediate effects 
are not good; in others their habitual use would only prove 
mischievous. 

Of local applications, counter-irritation and heat in some 
form may prove helpful in mild cases; hot cloths, frequently 
changed, often afford relief even in so severe a form as sciatica. 
Chloroform-liniment and oleates of morphia, atropia, or bella- 
donna may also prove useful. The thermo-cautery has ren- 
dered good service in the chronic forms of neuralgia and in 
zona. 

Electricity is beyond doubt of great value in some cases, al- 
though its employment offers many perplexing questions which 



GENERAL AND FUNCTIONAL DISEASES. 503 

the highest authorities have not yet solved . Struernpell recom- 
mends the following forms of application: 1. Stabile action 
of the anode of a constant current on the affected nerve trunk 
over as great an extent as possible, especially on any painful 
point. The current must be increased gradually up to medium 
strength; there should be no great variations in the current or 
interruptions of it, and the sittings must be daily, occupying 
from three to six minutes. 2. In neuralgia of the larger nerves 
we should use a stabile descending (sometimes ascending) con- 
stant current, in which the anode is placed on the most central 
point of the nerve trunk available, or on the vertebral column, 
and the cathode on different peripheral points. 3. The faradic 
current also frequently acts very well. We faradize the nerve 
either with a moderately strong "increasing" current, or we 
apply the wire brush to the skin over the affected nerves. The 
latter method is very painful, but is often attended with excel- 
lent results. 

In brachial neuralgia the descending galvanic current should 
be passed along the affected nerves. In phrenic neuralgia the 
galvanic current should be used, placing one pole just outside 
the lower part of the clavicular portion of the sterno-cleido- 
mastoid, the other at the epigastrium. In intercostal neural- 
gia use the faradic or the constant current; if the latter, place 
the cathode on the vertebral column, the anode on the lateral 
and anterior painful points, using a reasonably strong stabile 
current. In sciatic neuralgia, especially -when there is muscular 
wasting, use the galvanic current, placing a flat electrode over 
the sciatic notch and using a smaller one along the course of 
the nerve. Struernpell recommends the faradic current, with 
wire brush. 

Other local applications in neuralgia are the hot iron, thermo- 
cautery, blisters and, particularly in sciatic neuralgia, the in- 
jection into the nerve of distilled water, sometimes of chloro- 
form. It has been found that the injection of pure water may 
afford as prompt relief from pain as though it contained mor- 
phia. A puncture may be followed by improvement; the needle 
should be thrust deeply into the most painful spot to the depth 
of two inches, and left there for fifteen or twenty minutes. 

Nerve-stretching and excision of the nerve are measures of 
last resort in cases which have resisted all other methods of 



504 DISEASES OF THE NERVOUS SYSTEM. 

treatment; of the two, the more radical operation has yielded 
the better results; in many cases, however, there has been re- 
currence of the pain. 

Aconite must always be considered in recent cases or in cases 
resulting from cold, especially from exposure to a severe cold 
wind. The pain is acute, sticking, often accompanied with 
numbness; the patient is intolerant of pain and presents the 
anxious and excited tossing-about which belongs to the rem- 
edy. The forehead may be involved, the pain being drawing, 
tense, numb, or pulsating. Neuralgic toothache; of brachial 
plexus; phrenic; sciatic; all of recent origin, with heat and 
fever. — Gelsemium. Nearly always associated with paralytic 
weakness and numbness of the affected parts, sense of great fa- 
tigue, general exhaustion, mental irritability or utter indiffer- 
ence, chilliness. Facial neuralgia; face looks puffed, dusky; 
blurred vision; wants to be left to herself. Deep-seated pain in 
the muscles of the back, hips and legs. Sciatica; legs feel heavy 
as lead and very numb; utterly tired out; characteristic fever. — 
Belladonna. In recent cases. Acts best in plethoric young- 
people; in cases characterized by sudden onset of the neuralgia 
and congestion. Ciliary neuralgia, with heat and throbbing 
in the eyes; facial neuralgia, chiefly on the right side; sciatic 
neuralgia. In all these the pains are throbbing and very severe. 
Paroxysms of pain, beginning lightly, increasing gradually 
until the}' reach a high degree of intensity, then stop suddenly 
to recur after a time. Great sensitiveness to touch or jar; sen- 
sitiveness to light and noise. Heat in the affected parts.— Cim- 
icifuga. Very useful in persons of rheumatic disposition and 
in cases due to ovarian and uterine disease. Facial neuralgia, 
involving vertex and occiput, extending even into the neck and 
spine. Ciliary neuralgia, with photophobia and asthenopia, 
sensation as though the eyeball were enlarged. Uterine and 
ovarian neuralgia, with great tenderness, especially on the left 
side. Phrenic and intercostal neuralgia. Often the pains are 
lancinating or like electric sho:ks. Very nervous and appre- 
hensive. Characteristic mental depression. — Arsenicum. The 
chief remedy in cases of long standing, with general debility, 
anaemia, chronic malarial poisoning. The constitutional char- 
acteristics are present, especially the exhaustion arising from 
tedious morbid processes, including caries and other organic 



GENERAL AND FUNCTIONAL DISEASES. 505 

disease. There is restlessness, anxiety and melancholia, often 
with titter despair, and possibly suicidal tendency from the 
actual suffering endured. The pains usually are "tearing," 
often burning. Visceral neuralgia may present these, and in 
their treatment Arsenic is important. Of permanent service in 
old cases of sciatica. Long experience with Arsenic has taught 
the old school to place upon it great reliance as one of the few 
medicines capable of producing positive effects. — China, like 
Arsenic, is particularly valuable in anaemic cases, but acts less 
profoundly. Trifacial neuralgia, about the eyes and supra- 
orbital region, worse from the slightest touch, often worse at 
night. Ringing in the ears. Great acuteness of hearing and 
smell, neuralgia of the second and third nerve. Spinal irrita- 
bility. Excessive sensitiveness of the skin, with aggravations 
of the pain from slight draught and touch. — Rhus toxicoden- 
dron. In "rheumatic" cases, from exposure to cold, wet, from 
overexertion. General muscular soreness, numbness and par- 
alytic weakness and stiffness. Great mental and physical rest- 
lessness, with sense of chilliness. Of especial value in sciatic 
neuralgia, with the above symptoms, the muscular soreness 
being intense, so that the patient, in spite of the severe aggra- 
vation caused by motion, is constantly trying to obtain relief 
by a change of position. Motion, in such cases, may be fol- 
lowed by clonic spasms of the muscles of the affected leg. — 
Spigelia. Pains burning, jerking, tearing, very severe, radiat- 
ing, worse from motion. Ciliary, facial, intercostal neuralgia; 
neuralgia of the bowels, about the heart, extending into the 
arms, with praecordial anguish. 

The following are less frequently called for: Arnica. Muscles 
feel sore and bruised; chilliness without fever; pain sharp, as 
from a nail or a knife; intercostal neuralgia, with soreness in 
the muscles of the chest; gouty tendency.— Bryonia. Rheu- 
matic cases; intercostal and sciatic form, with characteristic 
aggravation from motion, soreness from lying on the parts; 
lumbago. — Cedron. Clock-like regularity of the paroxysms. 
Trigeminal form, involving the supra-orbital nerve and right 
side of the face; severe pain in the eyeball, radiating into 
nose and face, with profuse lachrymation. Malarial poison- 
ing. — Chamomilla. In sensitive women and children who are 
peevish, impatient, exceedingly intolerant of pain. The pains 



506 DISEASES OF THE NERVOUS SYSTEM. 

are tearing, shooting, pulsating.— Clematis. Irritable testis; 
urinary irritation; worse at night in the warmth of the bed. 
Eczematous eruptions.— Coffea. Great nervous excitability 
and intolerance of pain. It seems as though the brain were 
torn to pieces; as if a nail were being driven into the head; he 
cannot endure the pain; toothache, relieved from holding ice- 
cold water in the mouth; gets worse again as the water gets 
warm. Great sensitiveness to external impressions; sleepless- 
ness; irritability of the heart.— Colocynthis. Pain boring, 
sharp and cutting, relieved by pressure; much soreness in the 
affected parts; facial and sciatic neuralgia. — Ignatia. Charac- 
teristic mental symptoms and. hysterical condition. Supra- 
orbital pain, boring, in a small spot; as if a nail were being 
driven into the head. Neuralgia of the face, with weeping and 
emotional excitement. Copious emission of limpid urine. — 
Mercurius. Useful when there is caries of the bones; facial 
neuralgia, with tearing pains, from taking cold, worse at 
night.— Mezereum. Neuralgic headache, beginning in the oc- 
ciput and extending over the whole brain, with tenderness in 
the scalp, the pain burning and boring, extending to eye and 
teeth, and even down to the shoulder. (T. F. Allen.) Ciliary 
neuralgia, pains radiating and shooting downward, with a 
sensation of coldness and soreness of the bone. Facial neural- 
gia, burning, boring, better for a short time from drawing-in 
cold air; neuralgia from decayed teeth. Intercostal neuralgia, 
especially after herpes or with eczema. — Natrum muriaticum. 
Trigeminal form, on the right side, supra-orbital, with sore- 
ness, vertigo, faintness, relief on perspiring, worse at 10 A. M. 
Eczema of the scalp. Chlorosis. Malarial cachexia (neuralgia 
appears in place of a chill.) Constipation.— Nux vomica. 
Supra-orbital and ciliary neuralgia, with numbness of the parts 
and running of water from eyes and nose. Lumbago; the back 
feels bruised and lame. General soreness.— Platina. Facial 
neuralgia, with numbness of the malar bones or feeling as 
though the parts were being crushed in a vise. Hysterical con- 
dition.— Plumbum. Anaemia. Abdominal and rectal neural- 
gia; visceral neuralgia; neuralgia occurring in connection with 
lesion of the spinal cord, intensely painful.— Pulsatilla. Neu- 
ralgia of the face; infra-orbital; in the teeth. Pains jerking, 
erratic, paroxysmal; with chilliness; better in the open air and 



GENERAL AND FUNCTIONAL DISEASES. 507 

from 'walking about. Characteristic mental symptoms. — Stan- 
num. Pain at first light, increases gradually, then gradually 
diminishes and disappears. Neuralgia of the face, bowels; in- 
tercostal.— Staphisagria. Sensation of a ball in the forehead 
or of a lump which cannot be shaken off. Easily angered. 
Moist eruptions. Neuralgia of the shoulder- joint and arms. — 
Sulphur. In scrofulous persons, affected with skin -troubles, 
of lithsemic tendency; periodic neuralgia, caused by suppresion 
of an eruption; neuralgia alternating with some form of erup- 
tion. Neuralgic headache, with sense of tightness and conges- 
tion in the head and heat on the top of the head. Facial neu- 
ralgia (right side), worse at night. Dryness and redness of the 
tongue. Characteristic constipation and constitutional symp- 
toms.— Thuja. Neuralgia of the head and face, violent in char- 
acter, as though a nail were being driven into the head, or stab- 
bing, with excessive soreness of the parts. Always much worse 
at night. Sciatic neuralgia (left side), extremely painful and 
with great soreness, so he cannot lie on the affected side. Inter- 
mittent neuralgia. Sycosis. 

SLEEP AND SOME OF ITS DISORDERS. 

"Natural sleep is that condition of physiological repose in 
^vhich the molecular movements of the brain are no longer fully 
and clearly projected upon the field of consciousness" (H. M. 
Lyman); in other words, sleep is a regularly recurring, physio- 
logical depression of the functional activity of the brain, during 
which the exhausted tissues of the body may recuperate. Un- 
consciousness is not necessarily sleep. H. C. Wood distinguishes 
as follows: sleep is that condition of unconsciousness in which 
the subject is readily aroused, and when aroused is easily kept 
awake by external stimulations or by his will-power; stupor, 
that condition in which the subject is aroused with great diffi- 
culty, and when left to himself relapses into unconsciousness; 
coma, that state in which it is impossible by external irrita- 
tion to restore consciousness. 

Sleep is preceded by a stage of weariness which is an expres- 
sion of the failing energy of the brain; there is heaviness of 
body and mind, thoughts flow slowly and often with apprecia- 
ble lack of clearness, the special senses are dulled, muscular fa- 
tigue is felt, the eyes are kept open with difficulty, and it re- 



508 DISEASES OF THE NERVOUS SYSTEM. 

quires a strong effort of will to overcome evident indisposition 
to further activity. The hypnagogic state, the stage of transi- 
tion from waking to sleeping, is characterized by a conscious- 
ness of approaching rest; the body settles into a position of 
comfortable relaxation, the eye-lids close, the special senses are 
lulled. There is at first an exaltation of the reflex energy of the 
spinal cord, as shown by the sudden muscular jerkings in per- 
sons who are exceedingly tired; soon this disappears. Of the 
special senses, that of hearing remains active longest, in part, 
probably, because the external portion of the organ of hearing 
remains exposed to external stimuli. Soon the power of voli- 
tion ceases, the logical association of ideas is temporarily lost, 
as are also the reasoning faculty and judgment, and the pro- 
found unconsciousness of natural sleep prevails. The average 
duration of sleep is about eight hours. It is "heaviest" during 
the first hour, reaching its maximum at the end of that time; 
during the next hour it diminishes rapidly; during the next five 
hours it constantly grows lighter, and vanishes at the expira- 
tion of about eight hours. Not only have scientific experi- 
ments (Kohlschuetter) proved this, but universal experience 
emphasizes the statement that the first sleep is heaviest and 
that wakefulness and dreams prevail during the early hours of 
morning. 

During sleep the respiratory movements are reduced nearly 
one-fourth in frequency; they are more largely costal than dia- 
phragmatic, and the act of inspiration is prolonged. The pul- 
sations of the heart are reduced ten, or more, beats to the 
minute in adults, and from twelve to sixteen, or more, beats per 
minute in children. The temperature is lowered; an elevated 
temperature during sleep always indicates a pathological con- 
dition (Demme). The secretions are diminished, as shown in 
the comparative dryness of the eyes and mouth and the less- 
ened pathological secretion of nasal catarrh; the amount of 
urine and other excrementitious matter is also much less during 
sleep than during waking hours. There is a lessening of the 
amount of oxygen absorbed and of carbonic acid gas exhaled. 
Whether, or not, the brain is ever to all intents and purposes 
fully asleep, without a single manifestation of intellectual ac- 
tivity, so that there is an absolutely dreamless sleep, is still an 
open question. Some high authorities affirm the contrary 



GENERAL AND FUNCTIONAL DISEASES. 509 

and maintain that the brain is always on the alert; if this be 
so, the profound unconsciousness of sleep is unreal and arises 
simply from failure of memory. 

The reduction of function is not uniform throughout; the 
functional activity of one organ may be wholly suspended, 
while elsewhere there is only partial cessation of function; 
actual increase beyond that which characterizes a state of wak- 
ing may exist in some part of the body; hence the phenomena 
of dreams and somnambulism. 

Insomnia or abnormal wakefulness may arise from irritation 
of the peripheral portion of the sensory apparatus or from cen- 
tral causes. To the former belong irritation of the organs of 
special sense which, in the milder and transient form, rarely 
cause more than passing wakefulness. Thus, the action of 
light upon the eye disturbs sleep. This is easily demonstrated 
by the inability of small infants to sleep when exposed to a 
bright light and the readiness with which adults will awaken 
from sound sleep -when the room is suddenly illuminated by the 
reflection from a fire or when the light from a burglar's lantern 
suddenly falls upon their face. It is also well-known that in 
the far north during the long and brgiht polar night the natives 
darken their room during the hours of sleeping, and that trav- 
elers in that country find the lack of refreshing sleep due to the 
absence of diurnal darkness a source of serious suffering, even 
illness. Furthermore, all know that the occurrence of a total 
eclipse at any time of the day is a signal for the entire animal 
world to compose itself to sleep. The sense of hearing remains 
comparatively active during sleep, and often persons who are 
otherwise heavy sleepers are quickly roused by noise, especially 
when their name is spoken. Per contra, habitual noise, or noise 
long maintained, as the noise made by the running of street- 
cars, frequently induces sleep, and its abrupt cessation at once 
awakens the sleeper. The other senses are more quiescent and 
less easily disturbed. Heat, especially humid heat, is an enemy 
to sleep; witness the hot, exhausting, sleepless mid-summer 
nights, especially when a southern wind prevails. Cold, if ex- 
treme, produces stupor and death; if severe, it excites wakeful- 
ness; if pleasing, it favors sleep. All people naturally seek a 
moderately cool room for a sleeping chamber; they are, how- 
ever, kept awake by cold feet. Pain is a very common cause of 



510 DISEASES OF THE NERVOUS SYSTEM. 

insomnia. It may be due to affections of the nerves of com- 
mon sensation or the result of some disturbance in the sympa- 
thetic nervous system. To the former belong such trifling 
causes as the stings of insects or the painful itching of an 
eczema or pruritus, and the intense suffering caused by a neu- 
ritis or the various forms of neuralgia. Colic, disturbances of 
the respiratory function, cardiac disorders, etc., are among the 
affections of the sympathetic nervous system which cause in- 
somnia. 

Sleeplessness due to a morbid state of the central nervous sys- 
tem frequently arises from cerebral Iryperaemia, such as may 
result from prolonged and violent mental excitement, favored 
b} T habitual ill health, overwork, the excessive habitual use of 
alcohol and tobacco, or anything that tends to disturb the in- 
fluence of the inhibitor}' centres ever the lower ganglia of the 
brain. If such a condition is maintained for a considerable 
length of time, nutrition becomes impaired, rendering the brain 
anaemic and irritable, so that it quickly responds to slight im- 
pressions, remaining persistently wakeful and, if asleep, 
aroused by the most trivial causes. A differentiation between 
these two states — cerebral Iryperaemia and cerebral anaemia — is 
excedingly difficult. A similar effect may be produced by the 
action of certain chemical substances upon the brain. To these 
belong coffee and tea; alcohol, taken in large amounts, gives 
rise to a condition of irritable weakness of which insomnia is a 
prominent symptom. Irritating substances may also reach the 
brain through the blood from imperfect elimination (liver, kid- 
neys, intestines) or from the absorption of various poisons 
(lead, mercur}% miasms, etc.). The wakefulness which so often 
forms a conspicuous feature of inflammatory diseases, degener- 
ative changes, new-growths, etc., are the combined effects of 
cerebral hyperaemia, direct irritation, and pain. 

Treatment of Insomnia. — Persistent wakefulness seriously 
interferes with the repair of the tissues of the body and leads 
to innutrition and premature decay. Danger of permanent ill 
effects is greatest in those cases in which no adequate cause 
can be found. If occurring in children, it frequently is the first 
indication of the approach of tubercular meningitis or of some 
of the acute infectious fevers; in adults it may be the precursor 
of some serious cerebral disorder, as insanriy. The appearance 



GENERAL AND FUNCTIONAL DISEASES. 511 

of persistent insomnia in the course of a protracted sickness 
must always be considered a threatening complication. 

The following are the most important agents used in the treat- 
ment of insomnia: Heat establishes an equilibrium of the ner- 
vous system. Hot baths are preferable and equally grateful to 
children and adults. The temperature should not be too high, 
but rather such as to constitute the bath a source of physical 
comfort to the patient, who should remain in it not to exceed 
ten minutes. A foot-bath or a sponge-bath may be used as a 
substitute if a full tub-bath cannot be had. Turkish baths, 
with shower-bath and massage, are excellent. Massage, prop- 
erly given, is exceedingly useful in the cases which arise from 
spinal irritation and severe nervous headaches. Most persons 
experience from it a sense of rest; in others it acts rather as an 
excitant. Electricityis useful in cerebr asthenia. Often the pas- 
sage, daily, of a mild faradic current from the back of the neck 
or from the stomach to the feet, proves very quieting. Food. 
Very important in cases arising from exhaustion; it should be 
hot, nutritious, soluble, and slightly stimulating. Milk is espe- 
cially valuable when heated, slightly salted and, if necessary, 
partly predigested. (Dissolve five grains of pancreatic extract 
in half a pint of warm water; add, with five grains of sodium 
carbonate, to one pint of milk; put into a bottle, and immerse 
for half an hour in a jug of hot water. — Lyman.) Koumyss is 
nourishing and a favorite with dyspeptics. Egg-nogg is 
usually relished and its effects are desirable. Meat-juices may 
be taken in hot water or hot broth; they are stimulants rather 
than food. Neurasthenics who suffer from insomnia should 
avoid any exertion or excitement during the latter part of the 
day, should not take tea or coffee at noon or night, should eat 
a light evening meal, and upon retiring drink a pint of hot 
milk. Cold sitz-baths are Sedative; the water should be of a 
temperature ranging from 90° to 60° F., the temperature being 
gradually reduced to 60° after the patient has entered the 
bath; one or two baths daily should be taken, from five to 
thirty minutes in duration. Alcohol is indicated when there is 
great bodily exhaustion, with cardiac weakness, muscular 
wasting and nervous irritability, a condition which is occa- 
sionally seen in the late stage of infectious fevers. It must be 
used with caution, since at times the effects are undesirable. 



512 DISEASES OF THE NERVOUS SYSTEM. 

Often it acts well in case of extreme exhaustion from severe 
pain. An ounce of brandy should be given in egg and milk. If 
prescribed in delirium tremens, it is well to add tincture of cap- 
sicum. In cases of old people, with feeble digestion, suffering 
from wakefulness, a hot toddy before bed-time is grateful and 
appropriate. Under no circumstances must enough alcohol be 
given to produce the slightest S3 r mptom of intoxication. 

Hypnotics. — No other class of drugs is so constantly abused 
by medical men who are ever ready to humor the whims of a 
patient, regardless of their real interests; in cases where their 
employment is based upon actual necessity, they prove an in- 
estimable blessing. Paraldehyde, a substance which is ex- 
ceedingly disagreeable to the taste, in doses of 45 to 160 
grains, is one of the most reliable hypnotics when insomnia 
arises from cerebral hyperemia, not from pain. It neither 
causes primary excitement nor cardiac depression. Yvon gives 
the following formula: Paraldehyde, gr. 20.00; spirits, 100.0; 
simple syrup, 75.0; tinct. of vanilla, 5.0. Of this mixture each 
ounce contains forty-five grains of paraldehyde. Dissolve this 
still further in sweetened water or beer to suit the taste. — 
Chloral hydrate is especially adapted to cases of insomnia 
resulting from exhaustion of the nerve centres; hence its useful- 
ness in the wakefulness which follows excessive and prolonged 
mental effort, in mania (puerperal) and in delirium tremens. 
From 20 to 30 grains may be given in water, preferably pep- 
permint water, to hide the taste — , to be followed in an hour by 
20 grs. more, if necessary. If the stomach is intolerant of it, a 
drachm of chloral may be suspended with white-of-egg and a 
few ounces of milk and administered in the form of an enema. 
Chloral, if continued long, is a powerful depressant; hence it 
must be used with care.— OpruM. When insomnia is due to pain, 
morphia, especially the sulphate of morphia, is indicated; the 
addition of atropia (gr. jfa to y^ to ever} r one-quarter 
grain of morphia) renders it less dangerous and at the same 
time more effective. It acts quickest and best used hypoder- 
mically, thrown into the loose areolar tissue beneath the skin, 
preferably at the outer aspect of the arm, care being taken to 
avoid blood-vessels. If for any reason it cannot be given hy- 
podermically, it may be administered per rectum, in solution or 
suppository. The rectum should first be thoroughly washed 



GENERAL AND FUNCTIONAL DISEASES. 513 

out with warm water. The dose is slightly larger than when 
given by the mouth. In some cases Codeine acts nicely; it is 
used in doses twice as large as those of morphia.— Bromides. 
In insomnia from overexcitement, worry, excessive fatigue, ex- 
cessive sexual excitement, hysteria, mania. The following are 
commonly used: lithium bromide, 20 grs. every one or two 
hours, until sleep occurs; sodium bromide, 30 to 4-0 grs. every 
two hours; potassium bromide, 30 to 40 grs. every two hours; 
calcium bromide, 20 grains every one to two hours. Some 
practitioners are in the habit of prescribing hydrobromic acid, 
25 grains, largely diluted in sugar water; its very disagreea- 
ble taste renders it objectionable to many persons. Occasion- 
ally bromides excite rather than quiet the patient; if so, mor- 
phine and alcoholic stimulants are indicated. — Other drugs occa- 
sionally prescribed for their physiological effects are: Digi- 
talis, when there is enfeeblement of the heart. Valerian, 
when there is great hysterical excitement (elixir of valerianate 
of ammonia when insomnia is caused by pain or great nervous 
exhaustion). Cannabis Indica, when the wakefulness is due to 
pruritus or ungratified sexual desire. Amyl nitrite, inhaled, 
when insomnia is caused by insufficient blood supply in the 
brain, as in case of aortic obstruction. Hyoscyamus, in chil- 
dren. Hops, best in form of a good beer, is often excellent in 
sleeplessness from overwork; it should be drunk just before 
going to bed. 

The treatment of insomnia as a feature of special disease is 
considered under the treatment of such affections. It may be 
added that in the sleeplessness of children opium must be used 
with extreme care; wakefulness in them often depends upon 
hunger, overeating or earache; or it may be a symptom of the 
early stage of an acute disease, or due to ill temper; these 
causes, discovered, will determine the treatment. In old age 
sleep is very essential, but wakefulness is a feature of many dis- 
orders of old age, and if there is marked insomnia, attention to 
the primary cause often proves the only intelligent way of 
meeting it. In fact, it is to be remembered that hypnotics are 
in reality make-shifts, and not, like the duly indicated remedy, 
capable of doing permanent and curative work. 

Narcolepsy is a neurosis characterized by an overwhelming 
desire to sleep, of short duration, and occurring at irregular 
33 



514 DISEASES OF THE NERVOUS SYSTEM. 

intervals. Attempts to classify the cases observed are not suc- 
cessful or of practical use. Morbid sleep may end in death. 

Somnambulism is a condition of sleep and unconsciousness in 
which the subject performs acts which seem to involve the exer- 
cise of consciousness and volition; in other words, it is a 
dream carried into action. The attacks occur in persons of a 
neurotic temperament, and it is probable that the neurotic 
tendency is really the determining factor in those cases which 
appear to result from injun^ or exhausting disease. Unlike 
dreams, which are most frequent during the early hours of 
morning, somnambulism occurs during the early part of the 
night, when sleep is most profound; this undoubtedly explains 
why the memor\^ takes no cognizance whatever of the occur- 
rence. The most important forms are: Somnambulic lethargy, 
a condition which outwardly resembles deep sleep; lasting from 
hours to weeks, even months, with complete unconsciousness 
throughout its course. Somnambulic lethargy may alternate 
with lucid letharg}', in which the patient is conscious of things 
which occur in her immediate neighborhood. Lucid lethargy 
may constitute one of the striking features of hystero-epilepsy. 
Somnambulic dreams are more common, and differ from the 
ordinary dreams in that they expend themselves upon the or- 
gans of external expression, hence are acted out; but they are 
not remembered. The "night-terrors" of children belong here. 
Acts of violence are sometimes done in this state, especially in 
very heav}' sleepers who are aroused with difficulty; thus a 
man ma} T fancy that he hears a noise, which he connects with 
burglars; he grasps a pistol and begins firing, possibly with 
fatal results to some other person in the room; when fully 
awakened, he remembers nothing of what has happened. In 
other cases the somnambulist merely gets out of bed, walks 
about as though perfectly conscious of his acts, often perform- 
ing startling feats, for instance in climbing, or engages in any 
of the common acts of daily life, as writing, sewing, studying, 
pla3 r ing on musical instruments, etc. The eyes ma} r be closed 
while he is evidently in full possession of vision; or, if open, they 
are impassive, without expression, not sensible to common irri- 
tation, as from a bright light; sometimes he may be induced by 
a word of command to return to his bed where he quietly goes 
to sleep; or he may resist, but after a time obeys and retires. 



GENERAL AND FUNCTIONAL DISEASES. 515 

The tactile and muscular senses are usually much exalted, hence 
the somnambulist may accomplish feats which in the waking 
state he would not undertake. Exceptionally, a dim remem- 
brance, like a dream, exists of what has occurred; or the events 
of one somnambulic paroxysm are remembered during a subse- 
quent attack, as in the case reported by Macario, where a 
young girl had been violated during somnambulic sleep and 
gave her mother the particulars during a subsequent attack. 
Moral perversions and insanity may accompany or follow such 
states. "The disturbance which these functional perversions 
of the nervous system bring into the course of life extends not 
only to the organs of sense, and to intellectual actions properly 
so-called, but it also sometimes awakens some instinctive exci- 
tation which surrenders the individual without any defense, 
and destitute of rational discernment, to the most deplorable 
impulses. He acts with the semblance of a freedom which he 
does not possess; he seems to prepare and combine certain ac- 
tions in the light of conscious volition, when he is in reality 
only a blind instrument, obedient to the irresistible mandates 
of an unconscious impulse." (Lyman from Mesnet.) Somnam- 
bulic life is a rare condition in which the subject appears like 
any other person, seemingly in the full possession of all his fac- 
ulties, but has periods during which he lives an existence 
wholly distinct from his normal life, these states being divided 
from each other by a more or less complete break in the chain 
of memory. To this class belong the cases of individuals who 
get lost and are found at great distances from home or who re- 
turn home, after having traveled over an extensive territory, 
having done business with experienced men who saw nothing 
abnormal in their appearance or actions, who in every way be- 
haved like persons who knew what they were about, and yet 
remember absolutely nothing of what occurred during the en- 
tire period. A case is related by Macnish of a young lady who, 
without any warning, fell into a long and profound sleep; -when 
she awakened from the sleep it was found that she had lost 
every trace of acquired knowledge; it had become necessary for 
her to learn everything over again, including spelling, reading, 
writing and calculating; gradually she became acquainted with 
the persons and objects around, "like a being for the first time 
brought into the world." After a few months she had a second 



516 DISEASES OF THE NERVOUS SYSTEM. 

fit of somnolency. On rousing from it, she found herself re- 
stored to the state in which she was before the first paroxysm, 
but ignorant of everything that had befallen her afterward. 
For more than four years she passed periodically from one 
state to the other, always after a long and sound sleep, and 
each state characterized by a distinct existence of its own. 
The hypnotic state is somnambulism artificially produced. 



ORGANIC DISEASES OF THE BRAIN. 
AFFECTIONS OF THE MENINGES. 

PACHYMENINGITIS. 

Pachymeningitis or inflammation of the dura mater occurs in 
the following forms: Pachymeningitis externa, an inflamma- 
tion of the external layer of the dura mater; it usually results 
from an injury (fracture of the skull) or from extension of in- 
flammatory action, as in caries of the bones (syphilis, disease 
of the middle ear), more rarely from septic infection. Large 
amounts of pus may be present, giving rise to pressure upon 
the brain, headache, delirium, convulsions, coma, pressure- 
palsies. The symptoms usually are vague and may consist of 
headache only. Pachymeningitis interna nearly always results 
from sepsis. Hemorrhagic pachymeningitis (hematoma of 
the dura mater) is characterized by the existence of superim- 
posed layers of an exceedingly delicate structure which is rich in 
blood-vessels, with tendency to rupture and the formation of 
circumscribed sanguineous cysts. It is frequently found with 
atrophy of the convolutions. It occurs as the result of trau- 
matism, alcoholism, syphilis, sunstroke, specific fevers, anaemia, 
etc. It is comparatively common in lunatics. The symptoms 
usually are vague, the patient complaining chiefly of headache. 
When, as the result of the haematoma, there is localized pressure 
upon the brain, there may be impairment of intellect, early con- 
traction and, later, irregularity of the pupils, aphasic sj^mp- 
toms, irregular exacerbations and remissions of temperature, 
choked disk, convulsions, and gradual paralysis of motion and 
sensation. Recurring haemorrhages are not infrequent and may 



ORGANIC DISEASES OF THE BRAIN. 517 

be followed by periodical headache, short periods of uncon- 
sciousness, transient paralysis, convulsive seizures, and even 
death when the bleeding is extensive. Paralysis may be bi- 
lateral (hematoma at the vertex and crossing the sagittal 
suture). 

The diagnosis of pachymeningitis is obscure. According to 
Ranney, this affection may be suspected when symptoms of 
gradual cerebral compression follow injuries to the skull, 
necrosis of the cranial bones or otitis media, or when in cases 
resembling meningitis or cerebral softening there is bilateral 
paralysis, contraction of the pupils, localized headache, tran- 
sient and recurring attacks of unconsciousness or paralysis, a 
slow pulse, strabismus, ptosis, and facial palsy. 

The prognosis is always grave, and especially in hematoma 
and in cases associated with caries or otitis media. Chronic 
alcoholism renders the prognosis almost hopeless. 

The treatment in the suppurative cases consists of evacuation 
of the pus by means of the trephine whenever its presence can 
be determined and its situation localized. In the non-suppura- 
tive cases the treatment must be directed to the primary cause; 
it embraces perfect quiet, a nutritious diet, abstinence from al- 
coholic stimulants, and the exhibition of the symptomatically 
indicated remedy. 

LEPTOMENINGITIS. 

An inflammation of the pia mater and arachnoid, with puru- 
lent or sero-fibrinous exudation beneath the arachnoid. The 
forms recognized are: acute meningitis, acute tubercular men- 
ingitis, and chronic meningitis. 

ACUTE MENINGITIS. 

A non-tubercular acute inflammation of the pia mater and 
arachnoid. 

iEtiology.— Acute meningitis is in reality a disease of early 
childhood, the greater number of cases occurring during the 
first and second years of life; but it is not infrequent between 
the sixteenth and forty-fifth year. In adults, it is seen about 
three times as often in males as in females. The disease may be 
primary, sporadic or epidemic; and is due to the same influences 
which cause cerebro-spinal meningitis. Nearly always it is sec- 



518 DISEASES OF THE NERVOUS SYSTEM. 

ondan-, commonly the result of extension from local disease of 
adjacent parts, especially disease of the cranial bones, caries of 
the petrous portion of the temporal bone, wounds of the scalp, 
and en'sipelatous and phlegmonous inflammations of the scalp 
and face; the meningeal inflammation occurs as the result of 
direct extension or of infection through the blood. It may com- 
plicate acute infectious diseases (scarlet fever, typhoid fever, 
small-pox, etc.); this applies particularly to pneumonia. Septic 
processes even in remote organs may cause it; thus it is com- 
paratively frequent in connection with ulcerative endocarditis. 
More rarely it complicates Bright's disease or gout. Its rela- 
tion to rheumatism, sunstroke, or excessive mental application 
is not yet determined. Exceptionally it is of syphilitic origin. 
Morbid Anatomy. — Intense localized or general hyperemia, 
with great dryness and opacity of the meningeal membrane, is 
after a few days followed by an effusion, usually moderate in 
amount and containing cellular elements, on the arachnoid in 
its sac and infiltrating the pia mater; exceptionally the effusion 
is very copious, and may by pressure empty the surface capilla- 
ries and flatten the convolutions of the brain. Later pus may 
be found on the arachnoid, on the pia mater, around the ves- 
sels and in the sulci of the convolutions. The nerve-sheaths are 
bathed in semi-purulent matter; the nerve-trunks may become 
involved, eventually undergoing softening and disintegration; 
adhesion between the dura mater and arachnoid may take 
place. Invasion of the ventricles may occur, their orifices of 
communication being closed; the ventricles then become dis- 
tended with serous or purulent fluid, and there may be an cede- 
matous and softened condition of the underlying brain-sub- 
stance. Gowers points out that great extension of the ventri- 
cles may be seen without inflammation, simply the result of oc- 
clusion of the orifices of communication. When inflammation 
is most active, the effusion is rarely limited to the ventricles, but 
may invade the cord and escape into the brain-space. Upon re- 
moval of the calvaria, the surface of the brain appears greenish 
from the exudation present; the meningeal vessels are engorged 
and lie as distinct red lines upon a greenish back-ground; the 
pia mater is thickened, reddened, opaque in spots, with spots 
of adhesion to the dura mater; creamy exudation is found in 
the fissures and sulci; the brain-surface is dotted with capillary 



ORGANIC DISEASES OF THE BRAIN. 519 

extravasations; cross-section through the white substance of 
the brain often shows puncta vasculosa, minute spots of extra- 
vasation. The affection is usually bilateral in septic cases, in 
cases associated with specific disease and in those of pneumonic 
origin; in the latter, the disease is commonly limited to the cor- 
tex; it is unilateral in cases arising from extension of local dis- 
ease, as caries of the cranial bones or otitis, and may then be 
associated with thrombi of the sinuses or abscess. According 
to Fagge, the presence of subdural pus is nearly always proof 
of extension from without. 

Symptoms.— The onset of the disease usually is sudden and 
its course rapid. It may begin with or without chill, in chil- 
dren nearly always with convulsions (strabismus), with in- 
tense pain in the head, sensitiveness to light and sounds, and 
paroxysms of violent exaggeration. There is fever with a tem- 
perature of 102° to 103°, sometimes higher, and a small, firm, 
tense pulse. The headache grows worse in spite of all at- 
tempts to relieve it; it is accompanied with vomiting without 
sickness at the stomach, constipation, and retraction of the ab- 
domen. The face usually is pale in the early stage, with injec- 
tion of the conjunctiva; sometimes it is flushed. The fever in- 
creases after a few days, and the so-called stage of delirium sets 
in. This may be maniacal, accompanied with hallucinations 
of sight and hearing, or, especially in older subjects, it may re- 
semble the delirium of typhoid fever. Jactitations, general 
restlessness, excitability, gesticulations, twitchings of the 
facial muscles, and rolling of the eye-balls in the orbit are com- 
mon accompaniments. There may be stiffness of the neck from 
contraction of the posterior muscles. There may be rarely, in 
adults, convulsions, hemiplegia and paraplegia. Embarrass- 
ment of respiration and deglutition indicate involvement of the 
medulla or of nerve trunks arising from it. Involvement of the 
cranial nerves manifests itself by squinting, ptosis, marked 
contraction, dilatation or inequality of the pupils, with dis- 
turbances of vision and hearing. The delirium gradually sub- 
sides, and the patient slowly drifts into an increasing stupor, 
with slow, irregular, intermitting pulse, oscillations and, later, 
dilatation of the pupils, grinding of teeth, picking at bed- 
clothes, and frequently facial paralysis. The urine or stool 
may be passed unconsciously or, there may be retention. The 



520 DISEASES OF THE NERVOUS SYSTEM. 

temperature increases steadily (106° to 108°), with a sudden 
fall to subnormal a short time before death; the pulse becomes 
thread-like; there is Cheyne-Stokes respiration, clammy cold- 
ness of the surface of the body, and death occurs from heart 
failure, asphyxia, or pulmonary oedema. 

The pulse in the beginning usually is rapid and tense, some- 
times slow and irregular. Henoch's teaching that an intermit- 
tent pulse is characteristic of meningitis is not borne out by 
facts. Respiration is slow and labored, accompanied with 
cyanosis, and may suddenly stop in case the lesion is in the 
posterior fossa. The headache often is accompanied with 
great tenderness of the scalp, but this does not bear a fixed re- 
lation to the site of the meningeal inflammation save when the 
pain persists in a circumscribed area. The so-called tache cere- 
brale is not of diagnostic significance, though it is frequently 
noted. Rigidit} r of the muscles of the neck, with retraction of 
the head, is seen oftener w^hen the base of the brain is involved 
than when the cortex is the seat of the inflammation. It occurs 
early and is of diagnostic value. Local spasms may occur 
here, as in tubercular meningitis, when the seat of the lesion is 
at the base. Vomiting of cerebral origin is present in nearly 
all cases; it is most characteristic of the early stage. 

Subacute leptomeningitis differs in no essential from the form 
described; it is simply a milder form, running a more deliberate 
course. 

Diagnosis.— The diagnosis of simple meningitis is beset with 
difficulties, since many of the most characteristic symptoms 
may be found in other morbid conditions when there is no 
meningeal lesion. Gowers points out that even the general 
brain-symptoms are of slight diagnostic value, save as they are 
considered in their relation to other symptoms. Thus "the sig- 
nificance of the headache depends on its intensity'; of the de- 
lirium, on its existence with headache; of vomiting, on its 
causeless character and persistence; of general convulsions, 
on their association with other sy^mptoms; of infrequency of 
pulse, on its combination with pyrexia that usually accelerates 
the heart." The cases arising from disease of the cranial 
bones, otitis, or p3 r asmic processes are not so likely to escape 
recognition; in others it ma}' be impossible to differentiate from 
the cerebral forms of fevers (as typhoid), except as in menin- 



ORGANIC DISEASES OF THE BRAIN. 521 

gitis the involvement of nerves at the base, giving rise to optic 
neuritis and paresis, at once clears up the diagnosis. From the 
tubercular form it may be distinguished by the greater abrupt- 
ness of its onset, the greater rapidity of its course, the possible 
presence of primary local disease, the absence of a tubercular 
family -history and of tubercular disease in some other part of 
the body, and, often, the absence of involvement at the base of 
the brain. 

Prognosis.— Although it is claimed that occasionally cases of 
meningitis recover, the prognosis is very serious. It must be 
borne in mind that a mistake in diagnosis is easily made, and 
this fact has its bearing upon the prognosis in the individual 
case. The grave character of the affection imposes great cau- 
tion in the treatment of diseases in which extension to the 
meninges is comparatively frequent; yet, in these cases, as in 
those of syphilitic origin, the outlook is slightly more encour- 
aging than in others. Involvement of both the convexity and 
base of the brain leaves slight room for hope; the absence of a 
tangible cause is a bad sign: the development of stupor, with 
dilated pupils, paralysis and very high temperature, fore- 
shadows a fatal termination. 

Treatment.— Surgical measures should be adopted when, as 
in otitis media or in injuries to the skull, the primary local dis- 
ease can be reached by such methods; if employed at all, they 
should be employed promptly and thoroughly, since they can 
accomplish very little after the meningeal lesion is fully estab- 
lished. Cases of syphilitic origin must have specific medication 
(mercury or potassium iodide). According to Ramskill (Rey- 
nolds' System of Medicine), freely indorsed by clinicians of the 
dominant school, the treatment of simple meningitis resolves 
itself into "three great remedial measures; first, blood letting; 
second, hard purging; third, application of cold water or ice to 
the head." The practical value of these "three great measures" 
is proved by the hopeless prognosis made by the same authori- 
ties. 

Outside of medication, which will be discussed later, there is 
little that can be done for the patient. Nourishing and easily 
digested food should be given as conditions warrant. The head 
may be shaved and cool applications persistently applied, 
cloths wrung out of cool water being changed at brief inter- 



522 DISEASES OF THE NERVOUS SYSTEM. 

vals. A good purge at the beginning cannot be considered ob- 
jectionable, and often appears to have a directly beneficial effect. 

TUBERCULAR MENINGITIS. 

An acute meningitis due to the presence of the tubercle 
bacillus; it is also known as Acute Hydrocephalus and Basilar 
Meningitis. 

Etiology. — Tubercular meningitis is either a local manifesta- 
tion of acute general tuberculosis or is secondary to tubercular 
disease elsewhere. Heredity is strongly pronounced. It is 
largel} r a disease of childhood, most frequent from the second 
to the fifth or sixth year of life; occasionally it is seen in 
adults, chiefly men, during the third and fourth decade of life. 
It occurs with considerable frequency among the children of the 
poor, especially in cities, who grow up in want and amidst in- 
sanitary surroundings. It may develop during convalescence 
from one of the infectious diseases of childhood, especially scar- 
let fever and measles; it may follow an injury (blow or fall on 
the head) or overwork. 

Morbid Anatomy.— The deposit of miliary tubercles is in the 
perivascular lymph-spaces, where they appear as grayish-white 
granules near the vessels, sometimes compressing and even oc- 
cluding them. In children that portion of the pia mater which 
covers the base of the cerebrum is alone affected, but in adults 
the membrane covering the convexity of the brain, the longitu- 
dinal fissure and the cerebellum may be involved. "The favor- 
ite nesting place of the affection is in that portion of the pia 
which extends over the olfactory, the optic and the third 
nerve, as well as the crura cerebri." (Landon Carter Gray). 
Tubercles may be found in the brain-substance itself; their num- 
bers do not determine the extent of the exudation present. 
Under the microscope they appear as grayish-white, semi-trans- 
parent bodies. Not infrequently they form by confluence little 
nodules of the size of a pea; sometimes they are found to have 
undergone granular or cheesy degeneration. The resulting in- 
flammatory exudate consists of turbid serum or fibrino-puru- 
lent exudation, which is usually most copious in the Sylvian 
fissures and inter-peduncular space, but may cover the entire 
base of the brain and extend to the lateral surface of the hemi- 
spheres and to the under surface of the cerebellum and to the 



ORGANIC DISEASES OF THE BRAIN. 523 

spinal meninges. The pia mater is thick, lustreless, moist and 
easily torn. The ventricles, especially the lateral ventricles, 
usually are dilated and contain an effusion, commonly serous, 
rarely purulent; if the effusion is very great, the cerebral con- 
volutions may become flattened and distorted. In some cases 
the spinal meninges are extensively involved, with copious exu- 
dation along the cord, while the exudation at the base of the 
brain is trifling. Evidence of general tuberculosis can nearly 
always be found by examination of other organs. 

Symptoms.— In nearly all cases the onset of tubercular men- 
ingitis is gradual. There is failing health, either in connection 
with existing general tubercular disease or associated with 
some one of the exciting factors already enumerated. The 
symptoms are those of general indisposition, fretfulness, un- 
willingness to play, pallor and dull expression of the face, rest- 
less and broken sleep, poor appetite, and progressive emacia- 
tion of body and limbs. 

After two or three weeks the first stage of the disease— fre- 
quently called the stage of irritation— sets in with headache, 
fever and vomiting, or with a convulsion. The headache is 
frontal, evidently somewhat paroxysmal, and appears to be 
intense, for the child, if old enough and strong enough to do 
so, quickly puts the hands to the head when coughing and ut- 
ters a sharp, short, piercing cry (the "hydrocephalic cry") as 
though hurt; pressure upon the fontanelle in a young child in- 
creases the pain in the head. The fever at first is not high, but 
it gradually increases, the temperature reaching 102° or 103°; 
the pulse is rapid, full, compressible, sometimes irregular. 

Vomiting is projectile, without nausea, and has no relation 
to eating. The tongue is dry and coated, red at the tip and on 
the edges. The pupils usually are contracted. There is much 
muscular twitching, especially of the face, with sudden start- 
ings. The child seems drowsy and wants to sleep constantly, 
but the sleep is^restless; the head is rolled from side to side or 
bored into the pillows; it cries out as though in pain and fre- 
quently jumps^up as though in terror. There may be delirium. 

After a period varying from seven to ten days, symptoms of 
depression set in, due to effusion at the base of the brain and 
into the ventricles {stage of depression) . Vomiting has ceased. 
The child lies dull, listless, slightly delirious; occasionally it still 



524 DISEASES OF THE NERVOUS SYSTEM. 

utters the hA'drocephalic cry, and shows by the expression of 
the face that there is still severe pain in the head. 

The bowels are constipated, the abdomen retracted and boat- 
shaped. The temperature usually is lower than during the first 
stage, and exceptionally may be nearly normal; the pulse also 
is less rapid, often quite slow and irregular. There is tonic 
rigidit} r of the muscles of the neck, so that the head is retracted 
and bores into the pillow; sometimes the muscles of the back 
are involved, even to opisthotonos; there is tenderness on the 
neck to pressure. General muscular excitement may be marked, 
and general convulsions are not infrequent. The pupils vary 
in size; usually they are dilated and respond reluctantly to 
light; there may be strabismus, sometimes optic neuritis. Re- 
spiration often is sighing; swallowing may be difficult; urine 
and faeces may be passed involuntarily. The tongue is brown 
and dry; the mouth, lips and tongue are covered with crusts; 
the faecal discharges are slimy and offensive; the urine is 
scanty, high-colored, slightly albuminous, rich in chlorides 
and phosphates. A blotchy er\'thema may cover the chest and 
abdomen. "Tache cerebrale"— the quick appearance of a red 
line when the finger-nail is drawn rapidry across the skin — is 
easily produced, but is not of diagnostic importance. 

The approach of the third stage (stage of paralysis) is 
marked by an increase in the severity of all the symptoms, a 
renewed rise of the temperature, and rapid, feeble, intermittent 
pulse, with gradually developing profound coma. There are 
general or partial convulsions and contractures of the muscles 
of the neck, back, and jaw, followed by permanent paralysis of 
some parts of the body. The latter ma}' assume the form of a 
hemiplegia when there is involvement of the cortical branches 
of the middle cerebral artery or softening of the internal cap- 
sule; or there may be monoplegia, usually of the face. Jack- 
sonian epilepsy has been noted in cases which have run a very 
protracted course. The pupils are dilated, and the eyeballs 
roll, so that the "white of the eye" shows excessively. There 
may be optic neuritis and paralysis of the ocular muscles. To- 
ward the close the pulse becomes more and more "threader;" 
the temperature, which may have reached 105°, or more, 
during this stage falls to 93° or 94° (there often is an ante- 
mortem rise of temperature reaching 108° or 110°), and 
death occurs from asphyxia, convulsions, or heart failure. 



ORGANIC DISEASES OF THE BRAIN. 525 

The duration of the disease varies from ten to thirty days 
after the appearance of cerebral symptoms. The course is rapid 
when meningitis is a complication of general tuberculosis and 
when, in adults, the convexity of the brain is affected. 

The diagnosis rests upon the history of the case, the charac- 
ter of the headache and vomiting, the constipation and shape 
of the abdomen in the second stage, stiffness and retraction of 
the neck, and ocular palsies. These symptoms readily distin- 
guish it from typhoid fever and other affections which in some 
respects resemble it. 

The prognosis is almost hopeless. 

CHRONIC LEPTOMENINGITIS. 

Chronic leptomeningitis may gradually develop from the 
acute or subacute form; it is found in connection with tubercles 
or gummata in limited regions of the meninges, and may result 
from traumatism, alcoholism, and sunstroke. 

The symptoms resemble those of the acute type, save that 
they develop slowly, are much less violent, and run a chronic 
course. When due to tubercular masses or gummata, the 
symptoms are identical with those of cerebral tumor and may, 
if the irritation is in the motor region, assume the form of 
Jacksonian epilepsy. Cervical opisthotonos is found in many 
cases, often preceded by convulsions, pain in the head, vomiting 
and moderate fever, followed by the gradual development of 
symptoms which are characteristic of the acute form, including 
facial hemiplagia in case the ventricular orifices are occluded by 
lymph. 

Therapeutics of Meningitis. — For the purpose of avoiding 
repetition, the measures which are most likely to be indicated 
in any of the forms of meningeal inflammation will be consid- 
ered under this head. 

Of the first importance are those profoundly acting remedies 
which exert a direct and favorable influence upon the dyscrasia 
which so often underlies the local manifestation. The tempta- 
tion is to slight them in favor of remedies which present a 
greater intensity of action in the cerebral sphere; but abundant 
clinical experience has shown that the truly "constitutional" 
remedies are capable of accomplishing far-reaching results. Of 
these, Calcarea carbonica, Sulphur and the Iodides, given 



526 DISEASES OF THE NERVOUS SYSTEM. 

in highly attenuated form, are here the most important.— Cal- 
carea carbonica deserves the most serious consideration in 
a child of fair complexion, fat, flabby, sluggish, backward, 
easily perspiring, with habitually cold feet, deranged nutrition, 
enlarged glands, open fontanelles, prominence of the abdomen, 
characteristic indigestion, etc., even though the inexperienced 
prescriber may hesitate to stake the issue of so serious a case 
upon its action.— Sulphur is of corresponding value in children 
whose skin is rough and covered with some sort of an erup- 
tion, or when sudden disappearance or suppression of an erup- 
tion antedates the meningeal disease. The mucous membrane 
of the mouth and at the orifices of the body is bright-red, sore, 
burning. There are present in such cases the well-known condi- 
tions which always suggest Sulphur, as characteristic skin- 
symptoms, eye-troubles, catarrhal affections, portal conges- 
tion, habitual constipation (dry and irritable rectum), burning 
heat of head, hands, feet, and the determined opposition of the 
child to come in contact with water. — Of the iodides, Calcarea 
iodata and Arsenicum iodatum are the most useful, but they do 
not rival Calcarea or Sulphur. Of the two, Arsen. iod. has 
much more restlessness, a greater degree of prostration, nervous 
irritability and emaciation. It is especially adapted to scrawny 
children of dark complexion, with hard glandular enlarge- 
ments, particularly about the neck. 

Not infrequently in the early part of the stage of irritation 
Aconite, Veratrum viride and Gelsemium are indicated, 
though rarely for long; if they respond promptly, they will 
favorably affect the entire course of the disease. In Aconite 
the pulse is hard, abrupt; in Gelsemium full, but rather soft; in 
Veratrum, full, strong, voluminous. Aconite has thirst, rest- 
less tossing about, and other well-known characteristics, and is 
particularly useful when the disease is connected with exposure 
to the sun. — Gelsemium has startings, jerking, trembling, par- 
alytic weakness of muscles, great tenderness in the occipital re- 
gion; the child lies in a half-stupor, with hot, moist skin, un- 
willing to be touched or moved. If moved or lifted from the 
pillow, the head and neck are drawn backward and the 
body stiffens. It sometimes is indicated during the paralytic 
stage.— Veratrum viride is closely related to cases in which 
there is violent convulsive action from the beginning, with 



ORGANIC DISEASES OF THE BRAIN. 527 

cerebral hyperaemia, rapid and excited, powerful action of the 
heart, double vision, sensory irritation, great rigidity and bend- 
ing backward of the neck and back.— Apis mellifica. Of espe- 
cial value after scarlet fever; it has yielded positive curative re- 
sults. Stupor, interrupted by piercing, hydrocephalic cry; roll- 
ing of the head from side to side; boring of the head into the 
pillow; great restlessness and irritability at night; spasms of 
individual muscles; general convulsions; convulsions on one 
side, paralysis on the other. Face hot and livid; tongue red, 
later dry, hot, trembling, covered with crusts. No thirst.— 
Belladonna. In full-blooded persons, the attacks beginning 
with symptoms of intense congestion and violent convulsions 
which follow each other rapidly. Opisthotonos. After scar- 
let fever or measles. Effects of sunstroke. Of no value beyond 
the early stage of irritation. — Bryonia. Follows well after 
Belladonna. Intolerance of motion is well marked; the child 
lies perfectly quiet to avoid the aggravation from moving, 
especially of the pain in the head. Face dark-red, livid; mild 
delirium; sensorial depression; constant chewing motion of 
the mouth; lips dry; drinks greedily. — Cuprum. History of a 
suppressed eruption; violent convulsions, with convulsive roll- 
ing of the eyeballs, clenched thumbs, pale face, blue lips; great 
sensitiveness in the region of the spine. — Helleborus niger. 
Apathy; profound stupor; boring of the head into the pillow; 
hydrocephalic cry; wrinkling of the forehead; the eyes are 
staring, sunken, rolled upward, insensible; chewing motion of 
the mouth; automatic motion of one hand and foot; urine 
scanty and dark. Or violent general convulsions with com- 
plete unconsciousness, failure of the eyes to react to light, sup- 
pression of urine; drinks greedily when water is offered him; 
action of the heart feeble; pulse small, tremulous, intermit- 
tent; coldness of the body.— Zincum (Zinc phosphor.) Great 
heat at the base of the brain; sudden startings, as though 
frightened; constant restless movements of the feet; tremulous- 
ness of the muscles, jerking and twitching; convulsions. — 
Cicuta virosa. Insensibility; jerking and twitching of mus- 
cles of the face and body; neck rigid, head drawn backward, 
boring into the pillow; sudden violent shocks throughout the 
entire body, followed by spasms; pupils widely dilated; stra- 
bismus. Face red, hot, sweaty.— Opium. In the last stage. 



528 DISEASES OF THE NERVOUS SYSTEM. 

Child unconscious; stertorous breathing; general coldness of 
the bod}-, especially of the extremities; face often purple, hot, 
sweaty; tremulousness of the head, arms and hands, with, oc- 
casionally, jerkings of the muscles. Eyes half-open; insensible 
to light. 

Consult also Mercury, Lachesis, Arnica, Glonoine, Hyos- 
cyamus, Stramonium, Lycopodium, Silica, Potassium iodide 
(syphilis). 



DISORDERS OF THE CEREBRAL CIRCULATION. 

CEREBRAL ANAEMIA. 

Deficiency of blood in the brain may be localized or general, 
usually the latter. 

The aetiology embraces pressure upon adjacent parts of the 
brain by exudations, extravasation of blood or new growths; 
compression or obstruction of arteries supplying the brain; 
general bloodlessness from haemorrhage; abstraction of blood 
from the brain by rapid distension of the blood-vessels in some 
distant part of the body (sudden distension of intestinal blood- 
vessels); general anaemia (fevers, chlorosis, starvation, etc.); 
vaso-motor disturbances (shock, fright). 

Symptoms.— Acute cerebral anaemia begins with dizziness 
and ringing in the ears, dimness of vision, sense of weakness, 
disorder of the special senses, cold sweat, followed by loss of 
power of voluntary movements, extreme pallor of the face, 
dilatation of the pupils, unconsciousness. Recovery is gradual, 
consciousness returning first. Rarely death takes place from 
failure of respiration. 

Slowly developing cerebral anaemia, if general, is character- 
ized by apathy, headache with dizziness and dimness of vision, 
tinnitus aurium, bodily and mental enfeeblement, sleeplessness, 
despondency, mental confusion, melancholia, hallucinations, 
sometimes faintings and convulsions. It has been suggested 
that Marshall Hall's "spurious hydrocephalus" may be in fact 
a cerebral anaemia of infant life. In local anaemia, due to pres- 
sure of tumors, thrombosis, emboli, etc., the symptoms differ 
according to the area of the brain which is involved. Thus, im- 



DISORDERS OF THE CEREBRAL CIRCULATION. 529 

pairment of vision results from involvement of the cortex of 
the occipital convolutions; impairment of hearing or smell 
from anaemia of the temporal lobes; aphasia from anaemia of 
the base of the third frontal convolution and its immediate vi- 
cinity. 

Treatment. — In syncope from acute anaemia the patient must 
at once be placed into the recumbent posture, cold water be 
dashed into the face, the body briskly rubbed, ammonia applied 
to the nostrils, and alcoholic stimulants administered. In the 
rare cases where this is not sufficient, it is well to apply a tight 
bandage around the leg or a roller bandage around both arms 
and legs; a weak saline solution, about a pint, thrown into the 
buttocks or transfusion is indicated in the last extremity. In 
the chronic form treatment must be addressed to the primary 
cause. 

CEDEMA OF THE BRAIN. 

This condition is closely associated with cerebral anaemia. 
The most pronounced infiltrations are found in the neighbor- 
hood of cerebral tumors and abscesses. An acute oedema also 
occurs in chronic Bright's disease. Moderate effusions are com- 
mon whenever there is atrophy of the brain. The symptoms 
are largely those of anaemia; but coma, convulsions and par- 
alysis may be present. 

CEREBRAL HYPEREMIA. 

This may be active or passive. Active cerebral hyperaemia 
is caused by sudden and severe chilling of the surface of the 
body, increased action of the heart, excessive brain -work, dila- 
tation of the cerebral arteries from weakness of their walls, 
sunstroke, alcohol, amyl nitrite. Passive cerebral hyperaemia 
is usually associated with defective venous return, and is seen 
in obstruction of the cerebral veins and sinuses, engorgement 
of the lesser circulation, pressure on the superior vena cava, 
prolonged expiratory effort and straining. 

In spite of the seeming simplicity of the subject, it is in reality 
involved in the greatest obscurity, and the symptoms con- 
stantly attributed to cerebral congestion may be safely attrib- 
uted to other and usually more complex causes. The simplest 
34 



530 DISEASES OF THE NERVOUS SYSTEM. 

form of hyperaemia of the brain is probably seen in the "con- 
gestive" headaches of plethoric persons, with marked flushing 
of the face and throbbing of the carotids; this condition, when 
very marked, may increase so that the symptoms reach a high 
degree of intensity, with deep redness and lividity of the face, 
vertigo, and loss of consciousness, sometimes with heavy, ster- 
torous breathing. It is quite probable that in such cases of pri- 
mary congestion there may be rupture of a blood vessel and a 
true secondary apoplexy. 

The treatment consists of the administration of Aconite, 
Belladonna, Glonoine, Veratrum veride or Gelsemium, as 
indicated by the symptoms. Much relief may sometimes be had 
from the use of a sharp purgative. 



DISEASES OF THE BLOOD-VESSELS OF 
THE BRAIN. 

CEREBRAL HEMORRHAGE. 

Haemorrhage results from the rupture of an artery, oftenest 
cf the middle meningeal artery. The haemorrhage may be men- 
ingeal, or take place into the cerebral substance, or into the 
ventricles of the brain. 

^Etiology.— Excepting cases of haemorrhage directly due to 
some injury, the great majority of cases are the result of weak- 
ening of the walls cf the vessels from disease (arterio-sclerosis) 
or from primary disease of the brain-substance (softening of 
the brain, carcinoma, etc.); of these, arterio-sclerosis is by far 
the more important; hence the greater frequency of cerebral 
haemorrhage in men as compared with women, and in persons 
past the age of fifty, as compared with the young. Whatever 
causes arterio-sclerosis (see article on "arterio-sclerosis") is in- 
directly a cause of cerebral haemorrhage. The term "apoplectic 
habit" refers to stout persons of more than average weight, 
usually broad-chested, with large head, round face, and short, 
thick neck, who, as experience has shown, are frequently the 
victims of cerebral haemorrhage. Given a vessel whose walls 



DISEASES OF THE BLOOD-VESSELS OF THE BRAIN. 531 

are weakened by disease, any sudden increase of blood pres- 
sure may rupture it; hence violent coughing (in children par- 
oxysms of whooping cough) or vomiting, severe straining at 
stool or during childbirth, a quickly made and great muscular 
effort, even a violent emotion (as intense anger) may become ex- 
citing causes. Cerebral haemorrhage may be an expression of 
a general hemorrhagic diathesis (as found in purpura hemor- 
rhagica, scurvy, and in pernicious anaemia and leukaemia); it 
may also occur in severe infectious diseases, as typhoid and ty- 
phus fever, small-pox, septicaemia). Meningeal haemorrhage is 
not infrequent in the foetus as an incident of severe labor. 

Morbid Anatomy. — The arteries which form the seat of the 
lesion show a condition of chronic periarteritis which weakens 
the wall of the vessel and results in small miliary aneurism, 
chiefly situated on the smaller branches of the cortical vessels. 
Upon section they appear as small, dark bodies, varying in di- 
ameter from 1 to 3 millimetres. Larger aneurisms occur in the 
branches of the circle of Willis. More rarely there is diffuse de- 
generation of the smaller vessels. 

The haemorrhage is meningeal usually as the result of vio- 
lence or of gross aneurism. The effusion may be found between 
the dura mater and the skull, or may be subdural, or between 
the arachnoid and the pia mater. If resulting from rupture of 
an aneurism on a larger vessel, the haemorrhage may be suffi- 
cient to extend high upon the cortex and to the cord; if arising 
from the middle cerebral artery, the Sylvian fissure is distended 
with blood. Extensive intracerebral haemorrhage may burst 
into the meninges. 

Intracerebral haemorrhage is more common on the right side 
than on the left and occurs usually in the parts supplied by the 
striate artery ("artery of cerebral haemorrhage." Charcot.) 
It may extend upward to the centrum ovale, outward to the 
insula, or inward to the lateral ventricles. Such haemorrhages 
necessarily result in extensive tearing of the brain-tissues and 
the formation of an irregular cavity whose wall is made up of 
ragged and torn cerebral tissue, with contents consisting of a 
mixture of blood and debris of the nervous elements. 

Ventricular haemorrhage is nearly always secondary, blood 
from a haemorrhage without bursting into the ventricle and 
not infrequently forcing its "way into the other ventricle, 



532 DISEASES OF THE NERVOUS SYSTEM. 

through the septum or the foramen of Monro. It occasionally 
occurs during childbirth and the puerperium, and in the foetus 
during birth. 

An extensive cerebral haemorrhage in one of the hemispheres 
of the brain necessarily increases its size, puts the dura on the 
stretch, and by pressure flattens the cerebral convolutions. 
The blood-clot, when fresh, is of dark color; absorption of the 
liquid portion and probably of the fibrin takes place in due 
time, and eventually the haemoglobin is converted into haema- 
toidinand pigment granules, with a change in color to a reddish 
brown. By moderate inflammation the clot then becomes en- 
capsulated in a wall of false membrane, the contents are 
softened and dissolved into a \ r ellowish fluid, bands of connect- 
ive tissue are projected from the cyst-wall, contracting the cyst 
itself and favoring the absorption of its fluid contents. These 
"apoplectic cysts" in favorable cases are formed in about two 
months after the haemorrhage; they remain stationary. If the 
effusion was small, the contents of the cyst may be absorbed, 
the walls approach each other, and here only remains the 
"apoplectic scar," usually of yellow color from remnants of 
blood pigment. 

A secondary degeneration (descending sclerosis), following 
the motor path downward, occurs when a clot of some size 
affected the motor centres or pyramidal tract. The descending 
degeneration proceeds from the motor centres of the cerebrum 
along the motor fibres (pyramidal tracts) into the posterior 
half of the internal capsule between the corpus striatum and 
the optic thalamus, continuing downward through the crus 
cerebri, pons varioli and medulla oblongata into the spinal 
cord. 

Symptoms. — Prodromata are noted in some cases; they con- 
sist of headache, languor, tinnitus aurium, occasionally numb- 
ness, tingling, some pain in the extremities and muscular weak- 
ness. The duration of these varies from hours to days and 
months. In by far the greater number of cases the onset is 
sudden. When the haemorrhage is severe, the patient, probably 
while engaged at his usual duties, especially when making a 
muscular exertion, suddenly drops unconscious, and is found 
unconscious and in a state of relaxation. In other and lighter 
cases the attack may occur during sleep; the patient is then 



DISEASES OF THE BLOOD-VESSELS OF THE BRAIN. 533 

found unconscious in the morning or he may awaken in the 
morning rinding himself paralyzed; or if the haemorrhage is 
trifling and does not take place in a sensitive part of the brain, 
there may only be vertigo, headache, and passing loss of con- 
sciousness or mental confusion, nearly always with nausea and 
vomiting; or the patient may have threatening symptoms, and 
may even be unconscious, but get better, and then relapse; or, 
again, there may be no loss of consciousness at first, only a 
dazed condition, but in a few hours there is one-sided paraly- 
sis, followed by unconsciousness and profound coma (ingraves- 
cent apoplexy); or a small haemorrhage, especially in the re- 
gion of the central arteries, may involve the motor paths and 
cause hemiplegia without loss of consciousness. 

The severity of the apoplectic seizures depends largely upon 
the extent of the bleeding and the rapidity with which it occurs 
(bleeding from large vessels being more dangerous than bleed- 
ing from small vessels), and upon the location of the haemor- 
rhage. The closer the location of the haemorrhage to the cor- 
tex, the more pronounced the symptoms ; haemorrhage in the 
deep portions of the brain (crura cerebri or pons) often only sets 
up slight disturbance. But the shock from haemorrhage into the 
deeper portions of the brain, i. e., the brain-stem, is much 
greater than the shock from haemorrhage into the cortex or 
into the white matter of the hemispheres. This is due to the 
fact (Duret and Heubner) that the arteries within the brain- 
stem are not only larger, but that the arterial tension is much 
higher, thus accounting for both the frequency of haemorrhages 
here and for the gravity of apoplectic symptoms from a haem- 
orrhage which would have done slight damage had it occurred 
in the cortex or white matter of the hemisphere. 

During unconsciousness the face may be flushed, the pulse 
full, tense and slow, breathing slow, deep and stertorous, and 
there may be normal warmth of the body (congestive type); 
or the face may be pale, the pulse rapid and feeble, breathing 
quiet, and the body cool (syncopal type). These "types," how- 
ever, are by no means clearly defined. Usually the pupils of the 
eye are fixed, staring, dilated, sometimes contracted. The 
bodily surface is moist. There may be Cheyne-Stokes breath- 
ing. The temperature may be normal at first, but is liable to 
fall somewhat within an hour, and may eventually become 



534 DISEASES OF THE NERVOUS SYSTEM. 

subnormal (95°); a rapid rise of temperature (104°, and more) 
takes place when the haemorrhage is in the medulla or pons; re- 
gardless of the location of the haemorrhage, a rapid rise of the 
temperature is always an unfavorable sign. There is an in- 
crease of one-half to one degree in the axillary temperature on 
the paralyzed side over that of the unaffected side. The urine 
and faeces are passed involuntarily; the former, after the at- 
tack, is found to contain albumin and sugar. Convulsions are 
rare, but may occur at any stage. While in this state of uncon- 
sciousness the extremities are motionless and limp, and it is 
difficult to determine whether, or not, there is hemiplegia. The 
presence of paralysis may be recognized from the inequality of 
the angles of the mouth, from the greater puffing-out of one 
cheek during expiration, from the absence of motion in one arm 
or one leg, and from the absence of reflex action and defensive 
movements (against, say, prick of a pin) on one (paralyzed) 
side. Instead of a lax condition of the extremities, strong tonic 
rigidity is observed in exceptional cases, nearly always on the 
side opposite the haemorrhage; it occurs usually, but not exclu- 
sively, when the lateral ventricle has become filled with blood. 

In unfavorable cases unconsciousness remains complete; 
breathing becomes more and more irregular, hurried and shal- 
low; the pulse grows rapid and weak; there is rattling in the 
throat and, after a high an te-mortem rise of temperature, the pa- 
tient passes away. In other cases death seems to result from 
the fever and constitutional disturbances arising from inflam- 
matory changes at and near the seat of the haemorrhage. Ex- 
treme rigidity of the extremities, often with exaggerated re- 
flexes, is common here. Trophic changes also complicate this 
class of cases in the form of a sloughing eschar or decubitus 
at about the middle lumbar region of the paralyzed side. It 
begins as a dark purplish erythema, from the surface of which 
arise vesicles or bullae, containing an opaque, bloody sub- 
stance; these rapidly terminate in destructive sloughing ulcers 
which in the process of separation frequently lay bare the deep 
tissues, even to the bone. Fatal cases usually terminate in 
from 24 to 48 hours, but death may occur within a few 
minutes after loss of consciousness, as in the case of haemor- 
rhage into the medulla. 

In the great majority of cases the patient recovers with slow 



DISEASES OF THE BLOOD-VESSELS OF THE BRAIN. 535 

return of consciousness. Exceptionally a relapse may take 
place from renewal of the bleeding, with increased liability to 
a fatal termination. The return to consciousness affords the 
opportunity for making a correct estimate of the paralysis 
which invariably results from the haemorrhage. 

The ordinary form of motor paralysis here noted is a simple 
hemiplegia on that half of the body which is opposite the 
seat of the haemorrhage. It is said to be complete when the 
face, arms and legs are involved; incomplete when only one or 
the other are involved. Of the two, the former is the more fre- 
quent. 

In the face the paralysis involves the same side as in arms 
and legs, since its relation to the cortical centres is the same, 
but the paralysis is practically limited to the lower part of the 
face. Thus, the forehead can be wrinkled equally on both sides, 
but one angle of the mouth hangs lower than the other and is 
drawn toward the healthy side; a voluntary muscular effort 
readily demonstrates this. The hypoglossal nerve is frequently 
somewhat involved, causing a deflection of the tongue, when 
thrust forward, toward the paralyzed side; to accurately de- 
termine the degree of this deflection the position of the tongue 
must be taken from the incisor teeth. The soft palate and 
uvula are rarely affected. Articulation may be somewhat dis- 
turbed; in some cases mastication is difficult from inability to 
retain the food between the teeth on account of impaired 
power of the muscles of the cheek. The arms are usually 
affected more severely than the legs, and may remain helpless 
after the use of the lower extremity has been largely recovered. 
With the exception of the trapezius, the muscles of the trunk 
almost always escape. 

The term crossed or alternate hemiplegia is used to describe 
paralysis of the face and limbs on opposite sides. It occurs 
when the seat of the haemorrhage is in the lower segment of 
the pons Varolii, the facial nerve, in such case, being involved 
after it has left its nucleus, while the involvement of the motor 
fibres of the arm and leg is above the point of decussation in 
the medulla. 

Exaggeration of the tendon reflex on the paralyzed side is 
common; the superficial reflexes usually are diminished or lost; 
the sphincters are rarely involved. The sensory disturbances 



536 DISEASES OF THE NERVOUS SYSTEM. 

are slight; hemianesthesia is found only in exceptional cases. 
Slight numbness and tingling may exist, but soon pass off. 
Disturbances of special senses are equally trifling; the acute- 
ness of hearing, taste and smell are usually somewhat dimin- 
ished. A temporary hemiopsia may quickly follow cerebral 
haemorrhage, and exceptionally a persistent hemiopsia may be 
associated with hemiplegia. Conjugate deviation of the eyes 
and head may occur during the stage of unconsciousness or 
even when there is no loss of consciousness; it may persist for 
a short time only or indefinitely; in fatal cases it usually dis- 
appears before death. The head and eyes generally are drawn 
very strongly away from the paralyzed side of the body, to- 
wards the lesion; the reverse ma}' obtain, i. e., head and eyes 
may turn toward the paralyzed side. Vulpian and Prevost 
taught that in a lesion of the hemispheres the head is drawn 
toward the lesion and away from the paralysis, but that in 
lesions of the mesencephalon it is drawn away from the lesion 
and towards the paralysis. 

The secondary symptoms seen in the paralyzed limbs are 
highly interesting. In very light cases the use of the limbs is 
recovered within a comparatively short time, and even the 
sense of weakness in them may gradually disappear. But 
even when hemiplegia is complete a certain amount of improve- 
ment takes place, and the patient's condition at the end of a 
few months has greatly changed for the better; it is notable 
that this improvement is much greater in the leg than in the 
arm, the patient often being able to get about, with the aid of 
a cane, when the arm remains practically useless. The shoulder 
joint is the last to show improvement. There is, however, 
more or less dragging of the affected leg, the toes cannot be 
taken from the ground, and the patient, by a conscious effort 
of the hip and knee, in walking swings the leg outward and 
forward in a half-circle. It is safe to affirm that any symp- 
toms which outlast the first six months will not materially 
improve after that. Contractures occur later in the perma- 
nent^ paralyzed limbs, and their development may be accom- 
panied with much pain. Charcot attributed their occurrence 
to secondary degeneration of the pyramidal tract. Here also 
the paralyzed arm suffers more than the leg. The fingers are 
flexed upon the wrist, the forearm is held in a position of par- 



DISEASES OF THE BLOOD-VESSELS OF THE BRAIN. 537 

tial pronation, and the tipper arm adducted. In the leg the 
contracture is usually seen best in the calf. The contractures 
differ from those of hysteria in that they do not disappear 
under an anaesthetic and are incurable. Hitzig called attention 
to the fact that these contractures are usually somewhat less 
pronounced in the morning than after the patient had moved 
about. In exceptional cases the paralyzed member remains 
permanently flaccid; this occurs oftener in the hemiplegia of 
children. Atrophy of the affected muscles is not great, and 
they react readily to electrical excitation. -Tremors, choreic 
movements and athetosis are not uncommon, either as continu- 
ous movements or associated -with voluntary movements of 
the paralyzed, or even of the sound, side. They are most fre- 
quent in the hemiplegia of children. In some cases there is ar- 
thritis, chiefly in shoulder joint and knee, with redness, pain 
and swelling from purulent effusion and destruction of carti- 
lages and bone. The general health is not markedly affected, 
although the patient rarely maintains normal vigor of mind 
and body; usually he grows somewhat irritable and forgetful, 
and is easily provoked to laughter or tears; the body may be 
well nourished, but after years there is emaciation and special 
liability to fall a victim to intercurrent diseases. 

Diagnosis. — The diagnosis usually is difficult when the patient 
is first seen during profound coma. It is necessary to determine 
the existence of an injury to the head and whether, or not, there 
is hemiplegia. The latter is indicated by the presence of con- 
jugate deviation, rigidity or spasm on one side, and loss of tone 
of the muscles of one side as determined by raising the legs and 
arms and letting them drop, carefully observing and comparing 
the quickness and heaviness with which they fall. Inequality 
of the pupils, drawing of the face to one side, and ''puffing" ex- 
piration are also signs of apoplexy. Nevertheless, mistakes 
may be made, for the coma of alcoholic poisoning, of opium 
poisoning and of uraemia may present striking similarity to 
that of cerebral haemorrhage. In alcoholic coma the habits of 
the patient must be considered; the odor of alcohol may be 
detected in the breath; alcohol maybe found in the urine; coma 
here usually develops more gradually than in cerebral haemor- 
rhage, and is rarely as profound; the pupils show no inequality. 
It must, however, be remembered that cerebral haemorrhage 



538 DISEASES OF THE NERVOUS SYSTEM. 

may exist with profound alcoholic intoxication. Ursemic 
coma ma}' usualh r be distinguished by r the presence of albumin 
and casts in the urine and of oedema or general anasarca; hence 
the necessity of prompt catheterization and examination of 
urine in suspected cases. The coma of opium-poisoning develops 
more slowly than that of cerebral haemorrhage; breathing is 
more uniformly stertorous and slow, and the pupils are strongly 
contracted. Haemorrhage into the pons bears very close re- 
semblance to poisoning with opium. The coma of epilepsy is 
preceded by convulsions; the history of previous seizures deter- 
mines the diagnosis. The arthritis which ma}' develop in the 
course of hemiplegia differs from chronic rheumatism in its 
tendency to destruction of cartilage and bone. It is often 
limited to the paralyzed side, is associated with contractures, 
there is excessive tenderness to touch and movement, and 
rapidly developing oedema, with pitting on pressure. 

Prognosis — The prognosis as to recovery from cerebral 
haemorrhage must always be guarded. Unfavorable symptoms 
are: very profound coma; rapid rise of temperature immedi- 
ately after the primary fall; early formation of sloughing 
eschar; presence of a large amount of sugar and albumin in the 
urine; involvement of the pneumogastric nerve; pulmonary 
oedema; widely dilated pupils; paralysis of the sphincters. A 
favorable symptom is reaction on the second or third day, with 
moderate temperature followed by decline of the fever and 
returning consciousness. In aged people recovery is doubtful. 
Recovery ma}' be complete from limited cortical haemorrhage, 
especially after injury. Large haemorrhage into the white 
matter of the brain, into the ventricles, and about the base is 
rapidly fatal. Haemorrhage into the internal capsule is fol- 
lowed by persistent hemiplegia and contractures. Contract- 
ures and involvement of the joints are permanent. Involve- 
ment of the posterior fibres are often followed by hemianaesthe- 
sia, hemichorea or athetosis. 

So far as recovery from the hemiplegia is concerned, the pros- 
pect is good in slight paralysis of the arm and face without pro- 
found loss of consciousness; if motor aphasia is complete, 
speech rarely becomes quite natural; if complete hemiplegia in 
adults persists for ten days, a full recovery cannot be expected; 
symptoms which have persisted for six months may be con- 



DISEASES OF THE BLOOD-YESSELS OF THE BRAIN. 539 

sidered permanent; remaining clots or scars may become the 
cause of cerebral disturbances; there is a tendency to recurrence 
of cerebral haemorrhage. 

Treatment. — The patient must be put to bed without a mo- 
ment's delay, and in so doing every unnecessary moving of his 
person must be scrupulously avoided, for even passive motion 
may prolong or increase the bleeding. In bed, the head and 
shoulders must be placed with the patient lying on the par- 
alyzed side, to favor the escape of mucus and saliva from the 
mouth and to keep the tongue from falling backward and thus 
impeding respiration. Cold compresses may be applied to the 
head, or even ice-bags to the head and neck, if the haemorrhage 
appears to be severe. If the attack has occurred right after a 
hearty meal, it may be advisable to empty the stomach by 
irritating the pharynx with the finger, or by the stomach 
pump. The bowels also should be relieved by a copious enema 
or by placing upon the tongue a drop of croton oil. The 
bladder must be emptied at regular intervals. The tempera- 
ture of the room must be moderate, not more than 60°. Dur- 
ing the first twelve, or more, hours no food is to be given, but 
acidulated drinks may be freely used. Stimulants may be ex- 
hibited in case of great feebleness of the pulse and signs of 
approaching collapse. Particular pains must be taken to 
avoid the formation of bed-sores; hence there must be extreme 
cleanliness and the greatest possible care to avoid pressure, even 
to perfect smoothness of the sheet on which the patient lies. 
If, on account of coldness of the bodily surface, hot-water 
bottles are used, the danger of burns and their very serious 
consequences must be borne in mind. 

Local bleeding (leeches on the forehead) and venesection is no 
longer fashionable, and is now only practiced when there is ex- 
treme arterial tension. Dawbarn seeks to accomplish the same 
purpose by cutting off the return circulation from the lower 
extremities; to this end he uses an Esmarch bandage or tourni- 
quet as near the trunk as possible and just tight enough to 
materially obstruct the return flow through the veins without 
quite cutting off the current through the arteries; the pressure 
should be maintained for about an hour. To arrest the haemor- 
rhage, Horsley, influenced by experiments upon animals, ad- 
vises the ligation or compression of the internal carotid. 



54-0 DISEASES OF THE NERVOUS SYSTEM. 

As the condition of the patient improves, he may be given a 
liberal allowance of nourishing, easily digested food, of which 
milk and egg head the list. 

The treatment of the hemiplegia consists chiefly of massage 
and electricity. Neither should be employed until three or four 
weeks have elapsed; if emploj^ed sooner, they are more liable to 
do mischief than good. Massage must be given by a person of 
experience and skill, and should be used once or twice daily, not 
to exceed ten or fifteen minutes. The faradic current may be 
used when there are no degenerative changes, its strength being 
just sufficient to produce slight muscular contractions; it should 
be used daily, in seance's not to exceed ten minutes at first, and 
at no time longer than fifteen minutes. The galvanic current 
is preferable when changes of degeneration exist. Ranney 
advises galvanism until the faradic current shows its normal 
reaction. A very feeble galvanic current may be sent trans- 
versely through the head, for two or three minutes, or through 
the sympathetic nerve on the side of the haemorrhage. Cool 
baths, followed by brisk rubbing, not to exceed three baths in 
the week, nor too prolonged, are also advisable. The patient 
must eschew the use of alcoholic stimulants and tobacco, avoid 
overexcitement and severe physical or mental exertion, not use 
the eyes too constantly, and live a quiet life, spending much of 
his time in the open air. 

Veratrum viride is beyond doubt useful when there is very 
high arterial tension and the apoplexy belongs to the congest- 
ive type; there may be convulsions. — Glonoine. High arterial 
tension; congestive type of apoplex}"; valvular disease of the 
heart; renal affections. — Belladonna. In the early stage of 
congestive apoplexy, with throbbing and beating of the car- 
otids; face red and puffed up; convulsions; later, mouth drawn 
to one side; difficulty of swallowing; stupor; face deathfy pale. 
— Opium. Our most valuable remedy when there is profound 
stupor, insensibility of the pupil, redness, bloatedness and heat 
of the face, sweating (hot) of the head, rigidity of the body, 
coldness of the feet, convulsive movements and trembling of 
the limbs, slow, stertorous" breathing. "In threatening apo- 
plexy of drunkards; the occiput feels as heavy as lead, and 
there is a tendency to stertorous respiration, with free perspir- 
ation, which does not relieve, with spasmodic jerkings of limbs, 



DISEASES OF THE BLOOD-VESSELS OF THE BRAIN. 541 

numbness and variable pulse." (T. P. Allen.).— Lachesis. 
Symptoms threatening apoplexy, especially in drunkards and 
in persons who have atheromatous arteries; loss of conscious- 
ness; face blue, purplish; tremors in the extremity. Paralysis 
of the tongue, of the left leg. — Arnica. Heavy stupor, stertorous 
breathing; head hot, rest of the body cool; foul breath; stools 
passed involuntarily; "apoplectic habit." Paralysis on the 
left side. Is said to hasten the absorption of the clot. — Baryta 
carbonica "is an extremely valuable remedy in degenerative 
changes in the coats of arteries, aneurism, apoplexy as the 
result of senility," etc. — The treatment of the hemiplegia calls 
for Nux vomica or Strychnia, Causticum (paralysis of face, 
eyes, pharynx, arms, legs, with muscular contractions), Zincum 
phosphor., and others. 

CEREBRAL EMBOLISM A1VD THROMBOSIS (Cere- 
bral Softening:). 

The occlusion of a cerebral vessel by an embolus or throm- 
bus, causing arrest of circulation in the brain. 

^Etiology. — Embolism. The embolus usually originates in 
the left heart, as a vegetation in recurring endocarditis or from 
ulcerating segments; less often from clots from the appendix of 
the auricle or small white thrombi. Blocking of the branches 
of the circle of Willis may be caused by atheromatous patches 
on the aorta, portions of thrombi from an aneurism or 
thrombi from the territory of the pulmonary vein. The cardiac 
affections most likely to give rise to thrombi are the chronic 
valvular diseases. Large emboli may lodge at the bifurcation 
of the basilar artery; following the blood current, they may 
enter the left middle cerebral artery, less often the posterior 
cerebral and vertebral arteries, rarely the cerebellar vessels. 

Thrombosis or clotting of blood during life is usually due to 
the presence of an embolus around which the blood coagu- 
lates or to disease of the vessels. Of the latter, syphilitic en- 
darteritis is the most common, but it occurs also in simple en- 
darteritis. Other causes are: tubercular growths in the ves- 
sels, aneurisms, and ligation of the carotid. A disposition to 
clotting of blood is peculiar to marasmus, phthisis, chlorosis 
and the puerperal state. "Thrombosis and embolism may 



542 DISEASES OF THE NERVOUS SYSTEM. 

each give rise to the other. From every thrombus an em- 
bolism may be detached; and ever\^ firmly lodged embolus may 
form a nucleus for thrombosis." (Struempell.) 

Morbid Anatomy. — If in case of thrombosis collateral circu- 
lation can be established, which is difficult when the arteries 
are "terminal," no harm results; if collateral circulation is not 
established, degeneration and softening of the structures thus 
deprived of nourishment invariably results. The tissues perish, 
undergo disintegration, and are transformed into a soft, homo- 
geneous mass, composed of broken and swollen nerve-fibres, 
fatty granular cells, free fat-globules, and a few drops of 
myeline. Relief afforded at this time by collateral circulation 
may restore the tissues; this relief not being had, the fatty 
matter is absorbed, chiefly by the leucocytes; gradually further 
absorption of the dead and disintegrated tissues takes place, 
and eventually cysts and cicatrices are formed, as in the pro- 
cess of absorption of the blood-clot of cerebral haemorrhage. 
In case the softened area is superficial, a depression may result 
which is filled with serous fluid and by hyperplasia of the pia 
mater. The convolutions are atrophied, yellowish, and rather 
firmer than normal from the presence of cicatricial tissue. The 
color of the area of softening depends upon the presence of extra- 
vasated red corpuscles which by forming numerous little punc- 
tiform ecchymoses (capillary apoplexy) may give to the part a 
distinctly red or a reddish color. Yellow staining of the tissues 
arises from dissolved pigment of the disintegrated blood corpu- 
scles. ' 'White" softening means very slight staining of the parts. 

Symptoms. — Very extensive softening may occur and not 
give rise to symptoms during life, as is frequently the case in 
the yellow softening (plaque jaune) of elderly persons. In the 
greater number of cases, however, symptoms occur, and these 
bear a striking resemblance to those of cerebral haemorrhage. 

In embolism the onset is nearly always sudden and, in case 
of blocking of the left middle cerebral artery, aphasia may be 
associated with the hemiplegia. In thrombosis the onset 
usually is gradual, and premonitory symptoms like those pre- 
ceding cerebral haemorrhage (headache, vertigo, lassitude, 
numbness, tingling, mental incoherence", paralytic weakness) 
may persist for a long time. Paralysis occurs with or without 
sudden loss of consciousness, usually affects an arm, and ex- 



DISEASES OF THE BLOOD-VESSELS OF THE BRAIN. 543 

tends slowly. Sudden loss of consciousness is more frequent in 
embolism than in thrombosis. There may be temporary pal- 
sies, probably from the formation and, later, dissolution of a 
fibrinous thrombotic clot. The temperature, though not af- 
fected at once, usually rises to 101°. Convulsions occur oftener 
in embolism than in thrombosis. In some cases, as in the 
thrombosis of syphilitics, there may not only be loss of con- 
sciousness, but the patient may lie in a comatose condition for 
many days, even weeks; it is nevertheless very rare to see the 
threatening symptoms which characterize the profoundly apo- 
plectic state. The focal symptoms and the hemiplegia, with its 
secondary effects, do not differ from those of cerebral haemor- 
rhage. 

Occlusion of different arteries must of necessity be followed 
by symptoms which vary in accordance with the relation of the 
affected artery to certain parts of the brain and the functions 
which belong to them. 

Occlusion of the Carotid. — No symptoms, or hemiplegia which 
disappears after establishment of collateral circulation. An 
embolism or thrombosis may form in the skull and eventually 
invade the circle of Willis, causing coma and death or, if not 
fatal, hemiplegia and various palsies. 

Occlusion of the Vertebral Artery. — Usually hemiplegia, pref- 
erably on the side of the occlusion, with difficulty of swallow- 
ing and articulation, and temporary anaesthesia. Involvement 
of the nuclei in the medulla results from occlusion of the left 
branch (acute bulbar paralysis). 

Occlusion of the Basilar Artery. — Sudden death from involve- 
ment of the respiratory centres. In complete occlusion there 
may be bilateral paralysis and bulbar symptoms, with hyper- 
pyrexia and death within a few days. In case of partial re- 
covery, softening in the medulla and pons, with localizing 
symptoms. 

Occlusion of Anterior Cerebral Artery. — Usually establishment 
of collateral circulation through anastomoses between the an- 
terior and middle cerebral arteries. Sometimes loss of smell 
from softening of the olfactory bulb. Occasionally hebetude 
and dullness of intellect. 

Occlusion of the Middle Cerebral Artery. — The artery most 
frequently involved. If plugged low down, often permanent 



544 DISEASES OF THE NERVOUS SYSTEM. 

hemiplegia from softening of the internal capsule. Aphasia 
from involvement of the left artery. Occlusion above the arte- 
ries going to the centre of the brain gives rise to cortical par- 
alysis and aphasia (left artery); occlusion of the first branch 
causes softening of the third frontal, of the second and third 
branches softening of the ascending frontal, and of the fourth 
branch softening about the posterior limb of the fissure of 
Sylvius, with sensory aphasia. Ptosis may occur on the side 
opposite the hemiplegia. (Gowers.) 

Occlusion of the Posterior Cerebral Artery. — Abundant col- 
lateral circulation here often renders existing paralyses tem- 
porary. There may be hemianopsia from occlusion of the 
branch passing to the cluncus, and hemianesthesia from soft- 
ening of the posterior part of the internal capsule. 

Diagnosis. — It is practically impossible to make a positive 
diagnosis between cerebral haemorrhage and embolism or 
thrombosis. When the patient suffers from chronic valvular 
disease or some other affection which is likely to be the source 
of an embolus, when the patient is young, and when the exist- 
ence of embolism can be demonstrated elsewhere, as in the 
fundus of the eye, a diagnosis of embolism is safe. The symp- 
toms of cerebral haemorrhage are usually more profound, the 
stupor is more pronounced, and stertorous breathing is a con- 
spicuous symptom. 

The prognosis is always serious, and recovery from the par- 
alysis is less promising than in the forms arising from intra- 
cranial haemorrhage. 

Treatment consists of absolute rest, careful nursing, and the 
exhibition of such remedies as are symptomatically indicated. 
Cardiac stimulants should not be used, except as positively 
demanded by threatening heart-failure. Mercury and Potas- 
SIUM iodide are useful when there is S3 r philis. Otherwise the 
treatment indicated under "Cerebral Haemorrhage" and its 
secondary effects is applicable here. 

CEREBRAL ANEURISM. 

There are two forms: the small miliary aneurism and the 
gross aneurism of the larger vessels; of these, the latter is here 
considered. 

Aneurism is nearly always associated with simple or syphi- 



DISEASES OF THE BLOOD-VESSELS OF THE BRAIN. 545 

litic endarteritis (endocarditis), which results in weakness of 
the wall, dilatation of the vessel, and commonly embolism. 
Most frequently the middle cerebral arteries are involved. 

The size of an aneurism here varies from that of a pea to a 
walnut. The symptoms produced are those of pressure and 
irritation, according to its relation to other parts (thus, 
aneurism of the internal carotid may compress the optic nerve 
or the chiasma, resulting in optic neuritis). The aneurism may 
suddenly burst and cause apoplexy. A diagnosis is possible 
only in exceptional cases. 

THROMBOSIS OF THE CEREBRAL SINUSES. 

Thrombosis of the sinuses may be primary or secondary. The 
primary occurs in connection with exhausting diseases of child- 
ren (in young infants chiefly diarrhoea), chlorosis and anaemia, 
and in the terminal stages of phthisis, cancer, and other diseases 
characterized by a cachexia ("marantic" thrombus). The sec- 
ondary and more common form is the result of extension from 
other parts, as disease of the internal ear, suppurative affec- 
tions outside the skull, especially erysipelas; in the latter, ex- 
tension of the disease occurs along the nerves. In the secondary 
form the lateral sinus is commonly affected. 

Symptoms. — The condition may be latent, as in the involve- 
ment of only one sinus in young children, or the cerebral dis- 
turbances may be lost in the severity of other symptoms. In 
many cases there is headache, mental dullness, high fever, 
vomiting, coma, delirium and, later, localizing symptoms. If 
the longitudinal sinus is occluded in young children, there is 
dilatation of the veins of the scalp in the region of the great 
fontanelle, sometimes convulsions and vomiting, and occasion- 
ally exophthalmus. Thrombosis of the transverse sinus is 
usually associated with involvement of the jugular vein on the 
same side, often with painful oedema of the ear and mastoid 
region. In thrombosis of the cavernous sinus there is occlu- 
sion of the ophthalmic vein, followed by exophthalmus, 
oedema of the upper eyelid, swelling of the conjunctiva and 
face, chemosis, palsy of the oculo-motor nerve. In secondary 
thrombosis the symptoms are largely those of a secondary sep- 
ticaemia; there is headache, chills and fever, sometimes earache, 
vomiting, delirium, coma, convulsions; optic neuritis may be 
35 



546 DISEASES OF THE NERVOUS SYSTEM. 

present. A typhoid condition develops later, with death 
usually from pulmonary pyaemia. Pitts states that the ap- 
pearance of acute local pulmonary mischief or of distant sup- 
puration is almost conclusive of thrombosis. 

The treatment is limited to surgical measures. When it is 
possible to localize the thrombosis, trephining and evacu- 
ation of the sinus, with free drainage, may prove efficient. 
Pitts has tied the internal jugular vein in the neck, opened the 
lateral sinus, and scraped out the clot, followed by satisfactory 
recovery of the patient. 

APHASIA. 

"Aphasia in the widest sense of the word may be taken to 
embrace disturbances either at the sensory perceptive centres 
of hearing and sight and in the blind of the touch; of the emis- 
sive or motor centres of speech and writing; or of the psychical 
centres through which we gather rational conceptions of what 
is said or written, and by which we express voluntarily our 
ideas in language" ( Wm. Osier). Strictly speaking, aphasia is 
concerned with disturbances of the central apparatus, the re- 
ceptive, perceptive, and emissive centres in the cerebral cortex; 
disturbances of the centres which preside over the mechanism 
of speech are known as anarthria. 

Aphasia may be sensory or motor. In the former there is 
disturbance of the psychical and sensory perceptive centres; in 
the latter there is involvement of the emissive for speech and 
writing. 

Sensory Aphasia. — The power to recognize objects, their 
nature and character, is essential; its loss is known as apraxia, 
and is closely associated with many forms of sensor}^ and 
motor (ataxic) aphasia. 

The following description by Starr is clear and helpful: "It 
is a fundamental position involved in the accepted theor}' of 
cerebral localization that memories are the residua of percep- 
tions, and are therefore localizable in the regions of the brain 
concerned in perception. It follows that these memories form- 
ing the idea of an object or an action, being distinct from one 
another, may be lost by disease of the brain having a limited 
extent, and that the character of the memories lost will depend 
on the location of the disease. Now, cases have been recorded 



DISEASES OF THE BLOOD-VESSELS OF THE BRAIN. 547 

in which persons acted as if they no longer possessed such ob- 
ject memories, for they failed to recognize things formerly 
familiar. A fork, a cane, a pen may be taken up and looked at 
by such a person, and yet held or used in such a manner which 
clearly shows that it awakens no idea of its use. And this 
symptom, for which at first the term 'blindness of the mind' 
was used, is found to extend to other senses than that of sight. 
Thus the tick of a watch, the sound of a bell, a melody of 
music, may fail to arouse the idea which it formerly awakened, 
and the patient then has deafness of mind; or an odor or taste 
no longer calls up the notion of the thing smelt or tasted, and 
thus it is found that each or all of the sensory organs, when 
called into play, may fail to arouse an intelligent perception of 
the object exciting them. For this general symptom of ina- 
bility to recognize the use or import of an object the term 
apraxia is now employed. And since apraxia is a symptom 
which is very frequently associated with aphasia, and which, 
in fact, may lie at the basis of aphasia, it should always be 
looked for in a patient. To test for apraxia it is only necessary 
to present various objects to a person in various ways, and 
notice whether he gives evidence of recognition. * * * The 
patient may or may not be able to name these objects; that, at 
present, is not the question. But is it evident that the object 
awakens an idea in the mind?" 

The most important forms of apraxia are mind-blindness 
(visual amnesia) and mind-deafness (auditory amnesia). 

Mind-blindness may be functional and passing or a feature of 
organic disease of the brain. The affection usually involves 
the angular and supra-marginal gyri or the tracts which pro- 
cede from them, probably in the left hemisphere in right-handed 
persons and in the right hemisphere in left-handed persons. A 
patient afflicted with mind-blindness may see an object, but 
there is no intelligent impression of its character; he may see in 
a man standing before him some sort of an object, but will not 
be able to recognize this object as a man until the man speaks, 
and the auditory centres are thus utilized in the recognition of 
the person. Worcf-blindness is a condition in which the patient 
does not recall the appearance of words; he does not recognize 
them when written or printed. He may be able himself to write 
correctly, but, once written, the same -words convey no mean- 



548 DISEASES OF THE NERVOUS SYSTEM. 

ing to him. This condition is sometimes associated with mind- 
blindness and commonly with hemianopia. The seat of the 
lesion, in the greater number of cases, is in the angular and 
supramarginal gyri on the left side. 

In mind-deafness cognizance is taken of sounds, but they 
awaken no intelligent conception; much as the sounds of an un- 
known language, though heard, convey no meaning, awaken 
no auditory memories. TForcf-deafness is an inability to under- 
stand spoken language; the words are heard, but no longer 
possess any meaning. Cases of word-deafness are reported in 
which the patient was able to read, write and speak. 

In motor (ataxic) aphasia there is a loss of memory of the 
efforts which are necessary to set into action the speech- 
mechanism, the muscles of phonation and articulation. The 
patient is able to read to himself, not aloud, and understand 
what he reads, as he also understands conversation; but he is 
not able to reply. He knows what a certain object is, and what 
its uses are, but cannot call it by name, though he may be able 
to repeat its name after someone else has pronounced it first. 
The lesion is in the third left convolution. (Broca.) 

Other forms are: Agraphia or loss of the power of expression 
by written words; aglyphia or loss of the power of picture- 
making; ataxic amusia or loss of the power of expression by 
musical tones; musical agraphia or loss of the power of writing 
music; ataxic amimia or loss of the power of expression by 
gestures. Since any of the forms of aphasia may be complete 
or partial, the prefix "par" is used to indicate the latter; to 
illustrate, alexia means complete word-blindness, paralexia 
means partial word-blindness. 

Osier directs that the following tests be applied in each case 
of aphasia: (1) The power of recognizing the nature, uses and 
relations of objects, i. e., whether apraxia be present, or not; 
(2) the power to recall the names of familiar objects seen, 
smelled or tasted, or of a sound when heard, or of an object 
touched; (3) the power to understand spoken words; (4) the 
capability of understanding printed or written language; (5) 
the power of appreciating and understanding musical tones; 
(6) the power of voluntary speech, — in this it is to be noted 
particularly whether he misplaces words or not; (7) the power 
of reading aloud and of understanding what he reads; (8) the 



DISEASES OF THE BLOOD-VESSEES OF THE BRAIN. 549 

power to write voluntarily and of reading what he has written; 
(9) the power to copy; (10) the power to write at dictation; 
and (11) the power of repeating words. 

Usually aphasia is the result of organic disease of the brain- 
cortex or of the conducting nerve-fibres which pass from the 
cortex to the cord. Sometimes it is an expression of exhaus- 
tion of the brain and may be a feature of what has been called 
a "nerve-storm," or it may be hysterical, or, rarely, due to 
reflex inhibition from gastric or intestinal irritation. Disturb- 
ances of the function of speech are in all probability due to in- 
juries of nerve-fibres starting in the cortical centres, either com- 
missural fibres or fibres which pass directly downward to the 
lower ganglia. 

The treatment of aphasia demands special experience and 
special facilities, largely of an educational character; and these 
often prove ineffective. In young persons, education of the 
centres of the side of the brain opposite to the lesion often 
proves successful, and the patient learns to talk with readiness. 
In adults recovery takes place slowly and is not likely to be 
complete. Cases of complete aphasia with right hemiplegia 
are not promising. It may be accepted as a rule that motor 
aphasia of several months' standing without any improvement 
is hopeless. 

CEREBRAL PALSIES OF CHILDREN. 

HEMIPLEGIA. 

^Etiology.— According to statistics, this affection of children 
usually occurs during the first and second years of life and is 
infrequent after the fifth year has been passed; it appears to be 
somewhat more frequent in girls than in boys. Many cases 
undoubtedly result from cerebral haemorrhage, caused from in- 
jury received by the use of forceps during birth, or later from 
falls, and occasionally from violent paroxysms of whooping- 
cough. Cases are also seen at the height of infectious fevers 
(scarlet fever, measles, whooping-cough, etc.) or following 
them. In some instances they have followed punctured wounds. 
In about one-half of all the cases the disease sets in with severe 
convulsions. 

Morbid Anatomy. — The most common feature observed is 



550 DISEASES OF THE NERVOUS SYSTEM. 

cortical sclerosis and porencephalus, i. e., cortical cysts which 
communicate with the arachnoid spaces and penetrate deeply 
into the brain. The initial lesion is in doubt. 

Symptoms. — Frequently the disease begins with severe indis- 
position, fever, nausea and vomiting, followed by cerebral dis- 
turbances, chiefly stupor and convulsions, continuing for sev- 
eral days or even two weeks, or more. In other cases a rugged 
child, evidently in perfect health, is suddenly taken with con- 
vulsions and loss of consciousness; the convulsions may recur 
for several days, during which time unconsciousness persists. 
When consciousness returns, and the child begins to move 
about, hemiplegia (sometimes monoplegia) is noticed. Occa- 
sionally the palsy occurs suddenly or gradually without previ- 
ous serious illness, convulsions or unconsciousness. If on the 
right side, aphasia may be observed. Frequently the face is 
not involved. 

In many cases more or less complete recovery takes place, in 
the leg sooner and more fully than in the arm, although there 
is usually a slight hemiplegic gait. In the arm contractures 
are not rare; motion in it may be lost, save slight motion in 
the shoulder joint. In the majority of cases there is marked 
late rigidity; exceptionally the limbs are flaccid. Atrophy is 
pronounced; reflexes are heightened; sensation is rarely dis- 
turbed. There is frequently retarded mental development, oc- 
casionally bordering upon feeble-mindedness; epilepsy, local or 
general, occurs in a large proportion of cases, sometimes with 
idiocy; in still others, there are "post- hemiplegic" movements 
(Weir Mitchell) consisting of tremors and vibratory move- 
ments, or incoordinate choreiform movements, or athetosis. The 
latter, first described by Hammond, consists of involuntary 
and usually slow movements which are seen chiefly in the arms 
and hands, but also in the head, trunk, and other parts. If in 
the hand, the fingers are incessantly separated, extended, 
twisted, flexed, assuming all kinds of strange and phantastic 
positions. The interossei are chiefly involved. The articula- 
tions finally become so relaxed that an astounding lryperex- 
tension of the fingers becomes possible. These movements 
usually cease during sleep and are quickly aggravated from 
excitement. 



DISEASES OF THE BLOOD-VESSELS OF THE BRAIN. 551 



SPASTIC DIPLEGIA. 

A form of infantile paralysis with spasms of the extremities, 
usually dating from birth; it constitutes the most serious form 
of birth-palsies. It is caused by injuries received during a se- 
vere labor, as from obstetric forceps or some hurt to the 
cerebro-spinal meninges in case of a foot-presentation. Fre- 
quently there was asphyxia or convulsions of the new-born 
child. The pathological feature usually is a meningeal apo- 
plexy, with copious haemorrhage over the motor region. 

Symptoms. — In many cases the child at first appears normal. 
Later it is noticed that it has not full use of its arms and legs; 
attempts to walk show the disability of the legs; often the 
muscles of the neck seem unable to support the head. The child 
cannot stand on its feet; when it makes the attempt, it rests on 
the toes and inner surface of the feet; the legs may cross each 
other from spasm of the adductors. Rigidity of the limbs is 
remarkable, particularly so in the legs. Both muscular weak- 
ness and spasms usually show a preference for one side. Con- 
vulsions occasionally occur. Bilateral athetosis is seen in ex- 
ceptional cases, affecting the facial muscles as well as other 
parts of the body, and usually is very severe. The reflexes are 
exaggerated. Feeble-mindedness and idiocy are frequent. — A 
spastic paraplegia has been described and is not infrequent. It 
also is due to haemorrhage during delivery. The cerebral origin 
of the spasms and paralysis is strongly indicated by the pres- 
ence of other symptoms of brain disorder, as mental weakness, 
nystagmus, etc. 

Diagnosis. — The condition which must be differentiated from 
the birth palsies is the pseudo-paralytic rigidity of rickety 
children and of children suffering from debilitating disease, 
chiefly diarrhoea. Differentiation depends upon the association 
of this state of spastic rigidity with rickets, chronic diarrhoea 
and hydrocephaloid states; furthermore, the spasms here are 
usually limited to the hands and arms; the affection is painful, 
intermittent, and limited in duration. 

Treatment. — The convulsions must be managed as indicated 
under "Eclampsia." The paralyses demand the measures dis- 
cussed under "Cerebral Haemorrhage." The tendency to im- 
provement here should be a great incentive to put forth special 



552 DISEASES OF THE NERVOUS SYSTEM. 

efforts and to increase the extent of the recovery by close atten- 
tion to the diet of the child and to the maintenance of such care 
as will tend to keep its general health as nearly perfect as pos- 
sible. Deformities must be treated mechanically and surgically. 
Serious enfeeblement of the mind requires educational efforts 
which are more successful^ employed in public institutions than 
thev can be at home. 



INSULAR. SCLEROSIS OF THE BRAIN. 

A chronic disease of the brain, characterized by the existence 
in the brain (and usually in the spinal cord as well) of patches 
of connective tissue replacing the normal brain matter. 

^Etiology.— The affection belongs to adult life, chiefly to the 
third and fourth decade of life, but it may occur in the young. 
It seems to "run" in certain families and shows a slight prefer- 
ence for males. Its development often is insidious and without 
known cause. To some extent exposure, injuries and mental 
shock seem to be connected with it. Marie thought that the 
focal myelitis which follows certain fevers (scarlet fever, measles, 
diphtheria, etc.) may result in sclerosis. 

Morbid Anatomy. — The sclerotic patches are usually seen in 
the white substance of the brain, chiefly near the ventricles, 
centrum ovale, corpus callosum, pons, less often in the medulla; 
they are reddish-gray, slightly translucent, and measure from 
two to thirty, or even forty, millimetres. The cortex may look 
natural. The spots are nearly always seen in the spinal cord 
as well; sclerosis limited to the brain or to the spine alone 
hardly ever occurs. Under the microscope the plaques are 
found to consist of dense reticulated fibrous tissue, which in 
fresh cases often contains fatty granular cells. Charcot pointed 
out that the axis-cylinders resist for a long time and do not 
disappear until late in the disease. Fatty or sclerotic degener- 
ation is seen in the thickened walls of the blood vessels in the 
immediate neighborhood of the plaques. 

Symptoms. — The onset of the disease is insidious and difficult 
of recognition. The most characteristic symptoms are: Tremors. 
These are intentional, volitional, and may affect the arms, legs 
and head, but are most pronounced in the former, rendering the 
use of the arms difficult and uncertain. The tremors are un- 



DISEASES OF THE BLOOD-VESSELS OF THE BRAIN. 553 

equal, jerking, in this respect unlike the tremors of paralysis 
agitans. They are exaggerated by efforts to use the limbs and 
by mental excitement; they disappear usually during rest and 
sleep. Scanning speech, probably due to disturbance of motor 
innervation of the speech-organs from sclerotic involvement of 
the pons and medulla. Speech is labored, pronunciation slow 
and painstaking, there is a striking sameness in the pitch of the 
voice, and often tremulous movements of the lips and tongue 
while talking. Speech eventually becomes indistinct. Nystag- 
mus, slight, usually lateral oscillating movements of the eye- 
balls on fixation. 

Incidentally there may be seen vertigo, rarely coma; mental 
enfeeblement may occur; the sensations usually remain intact; 
optic atrophy is rare; late, the sphincters may become involved. 

Diagnosis. — This is not difficult in typical cases; in anoma- 
lous cases it maybe impossible. When the spinal cord is ex- 
tensively affected the case may present the appearance of a 
lateral or posterior spinal sclerosis. Frequently it resembles 
Friedreich's ataxia, but in the latter the tremors are not voli- 
tional, are much slower, and there is incoordination. 

The prognosis is exceedingly serious; in fact, hopeless. The 
course of the disease is intensely chronic and misleading. Re- 
markable temporary improvement occurs often, but eventually 
the patient becomes bed-ridden and dies from involvement of 
the medulla or from some intercurrent disease. 

The term miliary sclerosis is applied to small grayish-red 
spots scattered over the convolutions of the brain or found, as 
in a case of Gowers, at the junction of the white and gray 
matter; this condition causes no symptoms. Diffuse sclerosis 
involves an extensive area, an entire lobe or a hemisphere. 
When the cortex of one hemisphere is extensively sclerotic, it 
causes unilateral atrophy of the brain. Hemiplegia, diplegia, 
imbecility or idiocy are present in the greater number of cases. 
Tuberous or hypertrophic sclerosis consists of sclerotic areas 
on the convolutions, of opaque white color, very firm on sec- 
tion, and projecting somewhat beyond the surface of the con- 
volutions. 

The treatment of cerebral sclerosis is purely symptomatic 
and only serves to keep the patient as comfortable as possible 
and to maintain life. Arsenicum is of special value. 



554 DISEASES OF THE NERVOUS SYSTEM. 

INFLAMMATION OF THE BRAIN ; ABSCESS OF THE 
BRAIN ; SUPPURATIVE ENCEPHALITIS. 

-/Etiology. — Idiopathic abscess of the brain is rare. Nearly 
always infectious material has been carried to the brain, some- 
times through the blood from septic processes going on in dis- 
tant parts. Trauma is a frequent cause, involving wounds of 
the head (scalp), fractures of the skull (preferably compound 
fractures) and suppuration following local disease (periostitis, 
nasal polypi). Other factors are: Extension of suppurative 
processes arising from disease of the ear (otitis media, disease 
of the petrous bone). Septic processes in distant parts, as 
acute periostitis, ulcerative endocarditis, suppurative disease 
of the liver or lungs and pleura (fetid bronchitis, bronchiectasis, 
pulmonar3 r gangrene, empyema). Specific fevers and influenza. 
Struempell states that he saw several cases at the time of an 
epidemic of cerebro-spinal meningitis; he thinks it possible that 
their appearance was due to the same specific poison. 

Morbid Anatomy. — Suppurative meningitis is common in 
cases associated with trauma. Abscess may be solitary (in 
four-fifths of all the cases) or multiple, varying in size from 
that of a walnut to an orange, and larger. The pus usually is 
reddish white; if encapsulated, creamy and greenish, without 
odor or offensive (like sulphuretted hydrogen). The surround- 
ing brain-tissue usually is cedematous, and may be softened. 
In rapidly fatal cases suppuration may be diffuse. Oftenest the 
abscess is located in the white matter of the hemispheres. If 
near the surface, there may be considerable bulging and fluctu- 
ation. When due to injury or pyaemia, its seat usually is the 
frontal lobe and the centrum ovale; when arising from otitis, 
the abscess is nearly always located in the temporo-sphenoidal 
lobe or in the cerebellum. 

Symptoms. — In many cases abscess may form and exist for a 
long time in the brain without giving rise to symptoms; this, 
according to some authorities, applies particularly to idio- 
pathic cases and to those which result from trifling injuries. It 
appears, however, that the location of the abscess is a much 
more important consideration. It is well known that large 
abscess may exist in the frontal and lateral cerebellar lobe 
without for a long time giving rise to appreciable disturbance, 



DISEASES OF THE BLOOD-VESSELS OF THE BRAIN. 555 

evidently for anatomical reasons. In cases of abscess result- 
ing from extensive injuries, or developing acutely and rapidly, 
the symptoms are those of acute meningitis, i. e., rigors, irreg- 
ular fever with rapidly rising temperature, severe headache 
with pain often at the seat of the abscess, vomiting, either in- 
dependent of eating or after taking food. When resulting 
from otitis, symptoms of cerebral irritation are usually most 
pronounced at first, often with severe pain in the head and 
about the ear. Later there is drowsiness, mental apathy, with 
vomiting and sometimes, especially when the abscess is large, 
optic neuritis. Pallor, loss of appetite and emaciation are 
commonly present. Again, the latency of the symptoms may 
be prolonged even for months, no cerebral disturbances what- 
ever existing, or being so indefinite as to excite no suspicion of 
serious trouble. Suddenly violent headache, rigors, high fever, 
vomiting and coma set in or there appear focal lesions (apha- 
sia, facial paralysis, paresis of face and arms) which call atten- 
tion to the brain. 

Diagnosis. — This depends upon the demonstration of an ade- 
quate cause (see aetiology); upon the presence of symptoms 
which indicate cerebral disturbance; the exclusion of cerebral 
tumor by the presence of high and irregular fever and, often, 
rigors; the absence, usually, of choked disk; the rarity of dis- 
turbances in the area of distribution of nerves at the base of 
the brain (as paralysis of the motor oculi muscles). In case of 
abscess following otitis it is difficult to determine whether the 
abscess is in the brain, in the sinuses, or subdural. Localiza- 
tion of the lesion is important, but quite uncertain. In the 
frontal cerebral and lateral cerebellar lobe an abscess may 
exist indefinitely and not give rise to symptoms, save, perhaps, 
a certain degree of mental dullness. This also applies to the 
temporo-sphenoidal lobe, unless a very large abscess should be 
located on the left side, in which case the motor zone (face and 
arm) or the speech-centre may be affected. Abscess in the 
Rolandic region may cause convulsions from irritation or par- 
alysis from destruction of the centres. Abscess in the middle 
lobe of the cerebellum may disturb equilibration. Hemianopia 
may result from abscess in the parieto-occipital region, but 
even a large abscess there may create no disturbance. 



556 DISEASSE OE THE NERVOUS SYSTEM. 

The prognosis is unfavorable unless the abscess can be evacu- 
ated. 

The treatment then, is practically surgical, and under modern 
methods of operating the results achieved often have been highly 
gratifying. The usefulness of such remedies as Aconite, Vera- 
TRUM, Arnica and Gelsemium during the fever, and later of 
Arsenicum, China, Silica, and others, suggests itself. The 
value of a generous diet is evident. 

TUMORS OF THE BRAIN. 

Intracranial tumors may occur at any age, but are most 
frequent in early middle life; some new-growths, especially 
solitary tubercle, have a preference for the young. It is affirmed 
that men suffer from brain-tumors oftener than women. The 
following forms are observed: Syphiloma. These usually de- 
velop on the pia mater or on the arteries, are common in the 
hemispheres and pons, may be single or multiple, rarely exceed 
the size of a walnut, are irregular, rather soft, and on the grow- 
ing surface present a grayish, gelatinous appearance. Tubercle. 
They are single or multiple. Common in young persons of less 
than twenty years of age. Solitary tubercles may attain the size 
of a walnut. Occur in pons, cerebellum, cortex. Upon section 
prove soft, cheesy, yellowish; surrounded by softened tissue; 
may undergo calcification. Sarcoma. May develop in the 
brain substance, but oftener in the connective tissue of adjacent 
parts, dura mater, or in the cranium or its periosteal covering. 
Maj- be round-celled or spindle-celled. May form very large 
tumors, often at the base of the skull. May grow from within 
outward, perforate the skull and appear as an external tumor. 
Glioma and neuro-glioma. Originate in the neuroglia. They 
are not readily recognized because their outlines are indefinite 
and they shade gradually into the healthy tissue, producing 
some enlargement of the area invaded without materially 
altering its shape. Some are of slow growth, firm and hard; 
others grow rapidly, are soft and very vascular, sometimes 
giving rise to sudden bleeding into the new growth. They are 
found in the white matter of the cerebral hemispheres, also in 
the central ganglia, cerebellum, and in other parts of the brain. 
Carcinoma. Are nearly always secondary to cancer in other 
parts, chiefly of the breast, lungs, and pleura. May perforate 



DISEASES OF THE BLOOD-VESSELS OF THE BRAIN. 557 

the bone and appear as an external tumor (fungus haematodes). 
Cysts may be found in any part of the brain and of great diver- 
sity. Among them we find apoplectic cysts, chiefly about the 
basal ganglia; dermatoid cysts; porencephalus; cystic disease 
of the choroid plexus; parasitic cysts (cysticerci, echinococci). 
Rarely observed are fatty tumors, bony growths (in falx and 
tentorium), aneurisms, psammoma, cholesteotoma. 

Symptoms. — General symptoms. Certain general symptoms 
are found in all cases of new growth in the brain; they are 
largely the result of compression from the increasing enlarge- 
ment of the tumor. The convolutions are flattened, even 
obliterated; the dura mater is thinned and possibly perforated 
("worn through") or thickened by chronic inflammation; the 
very bones of the skull may be worn, thinned or perforated 
and their sutures loosened. Serous effusion into the ventricles 
is a common effect of the intracranial tension. Headache exists 
from beginning to end. It may be general or localized. If the 
latter, it is usually associated with tenderness upon pressure. 
The headache is generally dull, deep-seated, with sense of heavi- 
ness; it is aggravated from a jar, from stooping, from any cause 
that increases blood pressure. It varies in severity from a dull, 
endurable ache to pain of maddening intensity; it is continuous, 
-with periods of great exacerbation, especially at night. It is 
not always -worst at or near the seat of the tumor; thus, intense 
pain in the frontal region may be caused by a tumor in the 
cerebellum; on the other hand, persistent occipital headache 
indicates a new growth in the posterior fossa. The pain may 
radiate in the cranial nerves. 

Optic neuritis (choked disk) is present in four-fifths of all the 
cases (Gowers); usually it is double. It has nothing to do with 
the size of the tumor. Since optic neuritis may exist without 
loss of vision, it must be looked for by ophthalmoscopic exami- 
nation of the eye. It consists of "swelling of the disk, marked 
distension and tortuosity of the veins, possibly haemorrhage 
from passive congestion, and cloudiness of the disk, although 
the retina still exhibits its normal transparency." Eventually 
there is atrophy of the nerve, with partial or complete loss of 
sight. Mental symptoms. The patient grows dull, listless, 
stupid. He is indifferent to everything about him, takes no 
interest in anything. He talks slowly, looks weary and sleepy, 



558 DISEASES OF THE NERVOUS SYSTEM. 

pa3'S no attention to his dress or appearance. The memory 
becomes impaired. Often he is hysterical. Hallucinations and 
delusions are not infrequent. Vertigo and vomiting: Both are 
common and closety connected. The vertigo is particularly 
troublesome in tumors at the base and cerebellum, and is ag- 
gravated when arising from a recumbent position. It prob- 
ably depends upon disturbance of the central mechanism of 
equilibration. Vomiting has no definite relation to taking food 
and is not accompanied with nausea. It is frequent in all 
tumors about the central ganglia and at the base, and particu- 
larly prominent in the intracranial growths of children. Con- 
vulsions occur in many cases; they are of an epileptiform char- 
acter, and may be localized (Jacksonian) or general. Petit mal 
is rare. There may be tetanic rigidity of certain groups of 
muscles. Fever is not usually pronounced, save in cases of ex- 
ceptionally rapid growth of the tumor. Occasionally there is 
an increase in the temperature of the head, possibly over the 
site of the tumor. The pulse in the majority of cases is slow, 
from 45 to 60 beats per minute; it may be irregular. Emacia- 
tion is pronounced. Syncope and even apoplexy may result 
from haemorrhage into the substance of the new growth 
(glioma). Coma and Cheyne-Stokes breathing usually set in 
toward the end. 

Focal Symptoms — (After Osier.) — Central Motor Area. 
Symptoms are irritative or destructive. Irritation in the 
lower third may produce spasm in the muscles of the face, in 
the angle of the mouth, or in the tongue. The spasms with 
tingling may be strictly limited to one muscle group before ex- 
tending to others. (Seguin's signal symptom.) The middle 
third of the motor area contains the centres controlling the 
arm, and here, too, the spasm may begin in the fingers, thumb, 
muscles of wrist, or shoulder. In the upper third of the motor 
areas, spasm beginning in the toes, ankles, or muscles of the 
leg. Decide: the point of origin (signal symptom), the order or 
march of the spasm, the subsequent condition of the parts first 
affected, whether paresis or anaesthesia. Destructive lesions in 
the motor zone cause paralysis, often preceded by local convul- 
sive seizures in the arm, often due to irritation in these centres. 
Tumors in the neighborhood of the motor area may cause 
localized spasm; upon invasion of the centres, paralysis. On 



DISEASES OF THE BLOOD-VESSELS OF THE BRAIN. 559 

the left side, growths in the third frontal (Broca's) convolu- 
tion may cause motor aphasia. — Prefrontal region. Mental 
torpor and gradually developing imbecility. Aphasia from in- 
volvement of the lower frontal convolution. Neither motor 
nor sensory disturbances may be present. — Parieto-occipital 
Lobe. May be no symptoms. Word-blindness and mind-blind- 
ness when the angular gyrus is involved, and paraphasia. — Oc- 
cipital Lobe. Hemianopsia; blindness when the lesion is bi- 
lateral. If on the left hemisphere, may be associated with 
word-blindness and mind-blindness. — Temporal Lobe. No dis- 
turbance. In their growth involve the lower motor centres. 
Sometimes word-deafness if first and second gyri on the left 
side are involved. — Region of the Basal Ganglia. Hemiplegia 
from involvement of the internal capsule. Limited growth in 
either nucleus of the corpus striatum need not cause paralysis. 
Small tumors in the optic thalamus cause no symptoms, but, 
increasing, may cause hemianopsia and sometimes hemianass- 
thesia. Growths in this region are apt to cause early optic 
neuritis; by growing into the third ventricle, may cause disten- 
sion of the lateral ventricles. Pressure symptoms from this 
cause and paralysis due to involvement of the internal capsule 
are the chief symptoms of tumor in and about these ganglia. 
Growths in the corpora quadragemina usually involve the 
crura cerebri and cause marked ocular symptoms. Loss of 
pupil reflex; nystagmus. Should the third nerve become in- 
volved, there will be motor oculi paralysis on one side and 
hemiplegia on the other. — Pons and Medulla. Pressure-symp- 
toms. In disease of the pons the nerves may be involved alone 
or with the tract. In tuberculosis or syphilis a growth at the 
inferior and inner aspects of the crus may cause paralysis of 
the third nerve on one side, and of the face, hypoglossal and 
limbs on the opposite. A tumor growing in the lower part of 
the pons usually involves the sixth nerve, producing internal 
strabismus; the seventh nerve, producing facial paralysis; the 
auditory nerve, causing deafness. Conjugate deviation of the 
eyes to the side opposite that on which there is facial paralysis 
also occurs. Tumors of the medulla may involve the cranial 
nerves alone, or cause a combination of hemiplegia with par- 
alysis of the nerves. There is usually difficult swallowing, ir- 
regular action of the heart, irregular respiration, vomiting, and 



560 DISEASES OF THE NERVOUS SYSTEM. 

sometimes retraction of the head and neck, as signs of irrita- 
tion in the ninth, tenth, and eleventh nerves. The gait may be 
unsteady or, if there is pressure on the cerebellum, ataxic. There 
may be numbness and tingling, and convulsions. 

Diagnosis. — The diagnosis depends upon the gradual onset 
and the slow development of the case, with persistent and, 
usually, intense headache, choked disk, vertigo, vomiting, etc. 
The position of the tumor must of necessity be inferred from 
the focal symptoms. Several other conditions have one, or 
more, of these symptoms, but the totality of the symptoms in- 
dicating tumor appears reasonably clear. Thus abscess of the 
brain might easily be mistaken for tumor, but there is with it a 
history of trauma or the probability of septic infection; it has 
high and irregular fever, and choked disk is not present. Sclero- 
sis has not the choked disk, and the disease lasts much longer. 
It is very difficult at times to differentiate uraemia, which has 
intense headache and neuro-retinitis and general paralysis, on 
account of the presence of Jacksonian epilepsy. Cases of in- 
flammatory softening of the brain also might give trouble, but 
choked disk rarely occurs in connection with it and, unless 
rapidly developing, the symptoms are much milder than in 
tumor. 

The prognosis is unfavorable, with the exception of gummata. 
In tubercular growths encapsulation may take place and life be 
prolonged for many } r ears; but such cases are exceptional, and 
the pleasures of living may be marred by serious focal symp- 
toms, as blindness. Sarcomatous growths prove fatal in from 
six to eighteen months. Gliomata may exist for years. The 
average duration of all cases is probably about three years. 
Death usually occurs from coma due to increasing intracranial 
pressure or sudden failure of respiration from involvement of 
the respiratory and circulatory centres when the growths are 
near the medulla. 

Treatment. — Medical treatment is purely symptomatic; it 
aims chiefly to give relief from pain in the head and vomiting, 
and to meet pressing indications as they arise. Much may 
sometimes be done for the relief of pain by the exhibition of the 
"indicated remedy" (atropine is particularly useful); but after 
all, the help afforded amounts to little. Ice-bags are recom- 
mended for the headache, and the Paquelin cautery when the 



DISEASES OF THE BLOOD-VESSELS OF THE BRAIN. 561 

pain is occipital, but I know of no permanent good accom- 
plished by their use. In syphilitic cases large doses of iodide of 
potassium, continued daily for a long time, from six weeks to 
three months, have accomplished good results; hence the habit 
of "giving the patient the benefit of the doubt" by prescribing 
this drug even in cases where there is no reason to suspect 
syphilis. 

"Brain-surgery" has been successful in a limited number of 
cases. To undertake a radical operation it is necessary to 
definitely determine the location of the growth and to ascer- 
tain, by exploratory operation, its accessibility. To obtain 
good results, operative measures should not be deferred too 
long. H. C. Wood is probably correct in estimating that 
removal of the tumor is practical in about three per cent, of the 



CHRONIC HYDROCEPHALUS. 

A condition of the brain characterized by the accumulation of 
fluid in the ventricles. The term is also applied to the accumu- 
lation of fluid between the cortex and cranium (hydrocephalus 
externus; hydr. ex vacuo). It may be congenital or acquired. 

Congenital or infantile hydrocephalus may occur in the foetus 
and thus obstruct labor. Several children in the same family 
maybe afflicted. Its most striking sign is great enlargement of 
the head, particularly in the frontal and parietal regions. The 
bones of the skull become remarkably thin, almost as thin as 
paper, and nearly translucent. The sutures and fontanelles 
gape. The brain is atrophied, the hemispheres in severe cases 
possibly not exceeding an inch in thickness, the skull appearing 
like a bag containing fluid. The ventricles may be enormously 
dilated, chiefly the lateral, but often the third and fourth as 
well; their walls are more or less thickened and covered with 
minute granulations. The fluid of hydrocephalus is colorless, 
slightly albuminous, of a specific gravity of 1004 to 1006; the 
amount present varies from a pint to a quart, and often much 
more. 

In other cases the child at birth shows no evidence of any- 
thing abnormal, but after some weeks enlargement of the head 
is noticed; this may proceed rapidly, sometimes symmetrically, 
again showing the greatest increase antero-posteriorly. The 
36 



562 DISEASES OF THE NERVOUS SYSTEM. 

fontaneUes and sutures remain open; fluctuation may be dis- 
tinct, and brain-murmur (Fisher) may be heard. The distended 
bluish veins underneath the scalp appear as a close net-work. 
Depression of the orbital plates of the frontal bone results in 
exophthalmos. The remarkable enlargement of the head and 
its prominence especially in the frontal region gives to the face 
the appearance of excessive smallness; the head often hangs 
forward, as though too heavy. 

The mental condition of the child may be normal, but oftener 
there is enfeeblement and imbecility. There are motor disturb- 
ances, usually spastic symptoms, with exaggeration of reflexes; 
there is tardiness in learning to walk or inability to walk. The 
legs are more extensively involved than the arms; paraplegia is 
not infrequent. The sensations usually remain normal. Among 
motor irritations convulsions are the most prominent. There 
may be choked disk and optic-nerve atroplry. Exceptionally 
the disease is arrested and adult life is reached; in the over- 
whelming majority of cases death occurs within three or four 
years, usually from marasmus. 

Acquired Chronic Hydrocephalus (Hydrocephalus of adults) 
is a very rare affection and may occur spontaneously, without 
a known lesion. It usually depends upon the presence of a 
tumor at the base of the brain or in the third ventricle; some- 
times it is associated with closure of the communicating pass- 
age between the third and fourth ventricle or of Magendie's 
foramen, or it ma\-, rarely, follow meningitis. In adults hydro- 
cephalus may be extreme without causing expansion of the 
skull, but remarkable atrophy of the brain-substance then re- 
sults. The symptoms are headache, ataxic gait, optic neuritis 
without focalizing S3 r mptoms and coma with slow pulse. 

The diagnosis should present no difficulty in the congenital 
or infantile type, although exceptionally a rickety condition 
with thickening of the cranial bones may be mistaken for hy- 
drocephalus. But in rickets the shape of the head is rather 
square, the fontanelles do not bulge, and, according to Starr, 
thickening of the cranial bones is associated with hypertrophy 
of the facial bones. In the chronic hydrocephalus of adults a 
positive diagnosis cannot be made. 

Treatment. — The treatment of chronic hydrocephalus is 
wholly unsatisfactory. Recourse has been had to tapping 



DISEASES OF THE SPINAL CORD. 563 

(safest done by puncturing the anterior fontanelle), but the 
relief obtained has been of short duration. Methodical com- 
pression is practiced by diachylon plaster, bringing it over the 
head in strips from front to back, from side to side, and diago- 
nally. Care must be taken to produce even and not excessive 
pressure. Gray prefers the removal of a piece of bone, three to 
four inches long, an inch -wide, on each side of the median line. 
Bartlett calls attention to the results obtained by Nicita, 
Locatelli, and others, from exposure of the child's occiput to 
the direct rays of the sun for, at first, twenty minutes each day, 
gradually increasing to thirty and forty minutes. 

The remedies suggested by the totality of symptoms are Sul- 
phur, Psorinum, and Iodine (Arsen. iodat., Baryta iod.,Cal- 
carea iodat., Kali hydriod., Mercurius protoiod.); their 
usefulness lies in their profound constitutional effects and in 
their close relation to such constitutional, inherited tendencies 
as are found in hydrocephalic children. If there is cause to sus- 
pect syphilitic taint, the Iodide of potassium, possibly Thuja, 
is to be particularly considered. Apis, Bryonia, Hellebore, 
Zinc, and others, are indicated by symptoms described under 
"Tubercular Meningitis." If convulsions occur, they must be 
met by Belladonna, Cuprum, or other symptomatically in- 
dicated remedy. 



DISEASES OP THE SPINAL CORD. 

GENERA!, NOTES ON FOCAL LESIONS IN THE 
SPINAL CORD. 

The f ollowing hints, after Ranney, will prove useful: 
Focal Lesions in the Upper Cervical Region. — Hemiplegia re- 
sults from affection of one lateral half of the cord only; para- 
plegia from a lesion extending transversely to both lateral 
halves of the cord. Both hemiplegia and paraplegia will be 
complete below the head, with, possibly, anaesthesia of the en- 
tire body. Dyspnoea and hiccough from involvement of the 
phrenic nerve; arrest of respiration is prevented through the 
action of the pneumogastric nerves and continued expansion 



564 DISEASES OF THE NERVOUS SYSTEM. 

of the chest by the auxiliary muscles of respiration. In a sur- 
gical lesion, probable involvement of the respiratory centre of 
the medulla, with death from asphyxia; death from asphyxia 
not probable from paralysis of the phrenic nerves alone. In- 
volvement of cilio-spinal centre in lower cervical region may 
cause irregularity of pupils and increase of temperature in face 
and neck. Irritation or pressure upon the accelerating centre 
of the heart causes irritation and irregularity of the pulse. 
Slowly developing, non-traumatic lesions in this region have 
shown hiccough (phrenic nerve), acceleration of the pulse (irri- 
tation of accelerating centre of heart) and dyspnoea (phrenic 
nerve or nucleus of pneumogastric nerve in medulla), with 
paresis of arms, then chest, then legs. 

Focal Lesions of the Cervical Enlargement.— When there is ir- 
ritation of the cilio-spinal centre, there is usually dilatation of 
the pupils, pallor of the face, acceleration of the heart's action; 
pressure upon or destruction of these centres usually causes 
contraction of the pupils, flushing of face and neck, slowing of 
the heart's action. When the lesion is situated within the 
cervical enlargement, there is gradual paralysis of arms and 
legs; generally sense of constriction around the chest ("cincture 
feeling"). Lesion at upper part of enlargement; motor and 
sensory symptoms in legs, trunk, and in nearly all the regions of 
upper extremities, including the parts supplied by the brachial 
plexus above the clavicle. "Cincture feeling" at level of clavi- 
cles; dyspnoea often excessive. If in the lower part of the cer- 
vical enlargement: loss of faradic reaction of the muscles sup- 
plied by the ulnar nerve, often with atrophy of these muscles, 
chiefly flexors of wrist and small muscles of the hand. "Cinc- 
ture feeling" in upper part of chest. In severe cases paralytic 
condition of the muscles of the trunk (intercostals, triangularis 
sterni, accessory muscles of respiration) and of the abdominal 
muscles, embracing inspiration and expiration. Numbness, 
anaesthesia, paresis, or complete paralysis of lower limbs, in 
proportion to extent and severity of lesion. There may be par- 
alytic condition of upper extremities. In surgical injuries to 
the upper portion of the cord, often decided elevation of the 
bodily temperature, with slowing of the heart's action. 

Focal Lesions of the Mid-Dorsal Region of the Spinal Cord. — 
In the early stage, paresis of lower limbs and increased reflex 



DISEASES OF THE SPINAL CORD. 565 

excitability (rigidity and stiffness of affected muscles when try- 
ing to stand or walk). Later, paralysis and contractures. 
Sometimes tonic and clonic contractions. "Cincture feeling" in 
region of navel or lower ribs, sometimes of axilla, usually at 
highest limit of the lesion. Often paralysis of bladder and rec- 
tum, which may yet, by the aid of reflex action, expel their con- 
tents. Early, patient can hardly get to closet in time to empty 
bladder or rectum; later, urine retained sufficiently to cause 
overflow and dribbling (demands use of catheter). Sexual 
function not necessarily impaired. Rarely atrophy of para- 
lyzed muscles; electrical reaction normal or exaggerated. 
Paresis first felt in feet; gradually extends upward throughout 
lower limbs. 

Focal Lesions Above the Lumbar Enlargement of the Spinal 
Cord.— Sensory and motor symptoms resemble those of lesions 
in mid-dorsal region, but the reflex spasms of paralyzed muscles 
are less violent; still, they are prominent, and indicate increased 
reflex excitability of the gray matter of the cord below the seat 
of the lesion. Bladder and rectum also affected as in lesions of 
dorsal region. Sexual power about normal. Constipation 
from paralysis of rectum. Micturition slow and interrupted 
from paretic vesical weakness, with, later, retention and over- 
flow. In legs paralysis first noted in feet (sense of weakness 
and easy fatigue); numbness and anaesthesia extend as high as 
the groin or waist. "Cincture feeling" about waist below level 
of navel, at level of hips. 

Focal Lesions of Lumbar Enlargement. — If in lower part of 
this enlargement, incomplete paralysis with marked involve- 
ment of muscles supplied by the sciatic nerve (feet, legs, pos- 
terior aspect of thighs, region of the nates). Bladder escapes 
mischief; paresis or paralysis of sphincter ani. Sense of numb- 
ness usually precedes the paralysis; if posterior column of cord 
be involved, complete anaesthesia of parts supplied with motor 
power by the sciatic nerve. Absence of reflex movements when 
there is sufficient destruction to lead to impairment of func- 
tion; of paralyzed muscles if trophic function of cord be affected 
by changes in the ganglion cells of the gray matter. "Cincture 
feeling" usually about ankle, leg, or thigh. 

Focal Lesions Confined to Lateral Half of Spinal Cord.— In 
case of localized lesion (haemorrhage, fractured vertebra, con- 



566 DISEASES OF THE NERVOUS SYSTEM. 

tusion, etc.) exclusively confined to one lateral half, there re- 
sults ' ( spinal hemiplegia" and "spinal hemi-paraplegia." Any 
lesion of a lateral half of the cord causes anaesthesia of the op- 
posite side of the body, and motor symptoms on the same side 
of the body as the lesion. Lateral lesions and lesions affecting 
the entire cord are in their symptoms modified by the height of 
the lesion in the cord, for motor nerves and special centres in 
the cord itself are only affected when they lie below the seat of 
the lesion or are directly involved in the destructive process. 
When the seat of the focal lesion is high up in the substance of 
the cord, and the lesion is confined to a lateral half, the motor 
paralysis affects one side only of the body; the term "spinal" 
hemiplegia is then used to distinguish it from hemiplegia of 
cerebral origin. When the seat of the focal lesion is in the dor- 
sal region, and affects one lateral half only, the resulting motor 
paralysis involves one-half of the same side of the body below 
the seat of the lesion; this is called hemi-paraplegia. 

Spinal Hemiplegia— To be complete, the lesion must involve 
one-half of the cord and must be in or above the cervical en- 
largement of the cord. The result then will be: motor paraly- 
sis in the arm and leg of the side of the body corresponding to 
the seat of the exciting lesion, and paralysis of the trunk on the 
same side (clinical experience shows that the intercostal mus- 
cles often escape); paralysis of sensation on the side of the body 
opposite to the seat of lesion; involvement of the cilio-spinal 
centre in the cervical cord causes, in addition, inability of the 
pupil to respond to light (it still acts in the accommodation of 
vision for near objects) and redness and increase of tempera- 
ture of face, neck and ear of same side. There is also, from in- 
volvement of vaso -motor centres in the cord, elevation of tem- 
perature in the paralyzed muscles. 

Hemi- Paraplegia. —The result of focal lesion involving one 
lateral half in the dorsal region, hence below the cervical en- 
largement and the location of the cilio-spinal centre. Conse- 
quently there is no paralysis of the upper extremities nor in- 
volvement of pupil, face, ear or neck. There is paralysis of the 
muscles below the point of lesion and on the side of the lesion, 
sometimes with hyperesthesia of the integument on the para- 
lyzed side; also, sensory paralysis below the point of lesion, on 
the side opposite of the lesion. Often the bladder and rectum 



DISEASES OF THE SPINAL CORD. 567 

are paralyzed. The "band-like" feeling varies according to the 
seat of the lesion. The degree of reflex irritability or absence 
of muscular atrophy in the paralyzed parts depends upon the 
depth of the lesion in the cord and accompanying changes in 
the gray matter. There may be increase of temperature in the 
paralyzed limb. "Should the side affected with anaesthesia 
give any evidence of motor paralysis or muscular weakness or 
symptoms of anaesthesia appear upon the side where the motor 
paralysis is present, you may regard either one as conclusive 
evidence that the exciting lesion is progressing, and that the 
opposite lateral half of the cord is being involved to a greater 
or less extent." 

REFLEXES. 

Reflexes, to which frequent reference has been and will be 
made, are either superficial or deep. The superficial reflexes are 
excited by irritating the skin or mucous membrane by tickling, 
pricking, scratching or pinching the surface, or by the use of the 
electric wire-brush. The presence of the superficial reflex merely 
proves that the integrity of the particular nerve-arc implicated 
is intact; the absence of a superficial reflex proves absolutely 
nothing, for very many of them are inconstant or absent in 
persons who enjoy perfect health. The following are the most 
important superficial reflexes: The plantar reflex, contraction 
of the leg provoked by tickling the sole of the foot. The gluteal 
reflex, contracture of the gluteal muscles from stimulating the 
skin of the buttocks. The cretnaster reflex, tickling of the inner 
side of the thigh causing the drawing-up of one testicle. The 
abdominal reflex, causing contraction of the rectus and other 
abdominal muscles by stroking the skin of the lower flanks 
downward. The epigastric reflex, causing dimpling of the epi- 
gastrium on the stimulation of the corresponding side of the 
chest in the fourth, fifth and sixth intercostal spaces. The 
erector-spinal reflex, causing contraction of the erector-spinae 
muscles by stimulating the skin along their periphery. The 
scapular reflex causing contraction of some, or all, of the scap- 
ular muscles by superficial irritation of the scapular region. 
The palmar reflex, causing contraction of the flexors of the fin- 
gers by tickling the palm of the hand. Cranial reflexes, as: 
contractions of the muscles of the palate by tickling the fauces, 



568 DISEASES OF THE NERVOUS SYSTEM. 

or causing sneezing b} T tickling the nasal mucous membrane, or 
coughing by tickling the laryngeal mucous membrane, etc. 

The most important deep reflexes are: The knee-jerk (West- 
phal's symptom, patella reflex). In testing this, the leg is so 
supported that the foot clears the floor and the patient is di- 
rected to let the leg hang perfectly limber and to close the eyes. 
The tendon above or below the patella is then sharply struck 
with the edge of the hand, finger, or small percussion-hammer. 
If the patient is directed to clinch the hand firmly at the time 
the blow is struck, the contraction will be "reinforced," i.e., in- 
creased. It is estimated that the knee-jerk is absent in about 
two per cent, of persons in a normal state. 

The ankle-clonus (Achilles tendon reflex) is obtained by flex- 
ing the foot forcibly, so as to stretch the Achilles tendon. The 
calf-muscles contract and the foot is extended upon the leg; the 
muscles alternately and rapidly contract and yield while the 
pressure is maintained or until fatigued. The jaw-reflex is ob- 
tained by allowing the jaw to hang passively or l:w gently sup- 
porting it with one hand while with the other hand a sharp 
downward blow is struck on the chin with a percussion-ham- 
mer. 

ACUTE SPITVAL UIEIVI1SGITIS. 

An acute, non-syphilitic inflammation of the meninges of the 
spine. The terms pachymeningitis (internal or external) and 
leptomeningitis are used to describe inflammation of the dura 
mater or of the pia mater and arachnoid; clinically this distinc- 
tion is of slight value, since nearly always all the spinal mem- 
branes are involved. 

Etiology.— The chief cause is infection (pneumonia, scarlet 
fever, typhoid fever, small-pox, etc.), but cases occur as the re- 
sult of exposure to great heat or cold or from traumatism, in- 
cluding operations. Young males are especially liable to the 
disease. Pathologically the affection is identical with cerebral 
meningitis. 

Symptoms.— The disease frequently begins with a hard rigor, 
followed by fever, nausea and vomiting, and, usually, slightly 
accelerated pulse. In some cases the fever is high and the arte- 
rial circulation greatly excited. Within a short time pain sets 



DISEASES OF THE SPINAL CORD. 569 

in, which may be all along the spine or limited to the parts 
which stand in close relation to those segments of the cord 
which are nearest the seat of the meningeal inflammation. The 
pain in severe and constant, with acute exacerbations from 
movement of the spine, trunk, or limbs, and from pressure; the 
application of the electric current is unbearably painful. In a 
few hours motor symptoms develop in the form of violent tonic 
spasms, chiefly in the back, but also in the extremities; hence 
opisthotonos and vise-like flexion of the limbs. There may be 
convulsive twitchings, which are always exceedingly painful. 
The reflexes are highly exaggerated. Hyperesthesia is usually 
pronounced, often with impairment of mobility of the hyperaes- 
thetic parts; later anaesthetic patches may be scattered over 
the hyperaesthetic area. Focal lesions may be present, as fre- 
quent micturition or retention from involvement of the vesical 
centre, irregularity of the pupils from defective innervation of 
the cilio-spinal centre, profuse sweating from vaso-motor in- 
volvement, or bed-sores from trophic disturbances. Conscious- 
ness is usually not involved at first, but later on delirium and 
coma prevail, with death in from two to seven days from in- 
tense hyperpyrexia or paralysis of respiration and deglutition. 
In case of recovery there is nearly always left permanent con- 
tractions or paralysis, the result of injury to the roots of 
spinal nerves in the immediate neighborhood of the lesion. 

The diagnosis depends chiefly upon the constancy and se- 
verity of the pain in the back, often shooting along the spinal 
nerves, muscular rigidity, highly exaggerated spinal reflexes, 
and high fever at the onset. 

The prognosis is serious; as stated, recovery is rarely com- 
plete. The presence of symptoms indicating myelitis, great hy- 
perpyrexia, and extension of the inflammation to the medulla, 
are very unfavorable. 

Treatment. — Absolute rest in bed is not only essential, but is 
demanded by the patient; the diet, at first, should be light, 
later concentrated and highly nutritious. Among the "actively 
antiphlogistic" measures advised, active counter-irritation over 
the seat of the inflammation, as by actual cautery, and the use 
of cold or very hot applications are least harmful and may be 
actually useful. The direct application of ice to the head or 
neck is not advisable. When there is hyperpyrexia, the tepid 



570 DISEASES OF THE NERVOUS SYSTEM. 

pack is more helpful than cold applications; hike-warm baths 
would answer as well, possibly better, were it not for the in- 
tense pain caused by moving the patient. The bladder must be 
guarded against cystitis. When there is incontinence, overflow, 
or retention, the catheter is to be used at regular and short in- 
tervals and the bladder washed out daily. Bed-sores develop 
easily; hence any irritation or abrasion of the skin demands 
careful attention. Frequent bathing of the skin in alcohol and 
constant care to have the bedding both soft (air-cushions) and 
perfectly smooth, with occasional change of the patient's posi- 
tion, will tend to prevent this very annoying complication. 
When bed-sores do occur, they are to be treated according to 
recognized surgical principles, including the permanent water- 
bath. 

Aconite and Veratrum viride are both useful in the early 
stage, but in the early stage only; Veratrum is called for when 
the arterial tension is very great. Belladonna and Glonoine 
usually follow, especially so when there is marked congestion 
and convulsions early in the disease. Gelsemium has much 
less violent congestion, but is very useful when there is pain in 
the back of the neck, extending to the shoulders and spine, 
trembling weakness, paralytic condition of extremities, para- 
lytic weakness of the bladder, etc. The patient has control of 
his mental faculties, but, unless the pain is intense, he may lose 
himself in a stupid sleep, with low muttering delirium. Bry- 
onia is an excellent remedy, largely on account of its close rela- 
tion to the serous membrane; the characteristic indications are 
easily recognized. Cicuta virosa is probably the most impor- 
tant remedy after the first stage has passed; it practically 
covers all the manifestations of motor irritability which are 
likely tc occur, including marked tetanic rigidity (opisthotonos) 
and violent convulsions. Insensibility, with staring eyes, red, 
hot face, strabismus, difficult breathing, etc., may be present. 
Consult also Apis, Cuprum, and other remedies under Simple 
and Tubercular Meningitis. The various paralyses likely to re- 
main after recovery demand Nux vom., Strychnia, Causticum, 
Rhus and Sulphur; massage and mild currents of electricity 
must be applied to the atrophied muscles. 



DISEASES OF THE SPINAL CORD. 571 

CHRONIC SPINAL MENINGITIS. 

General Chronic Spinal Meningitis may follow acute spinal 
meningitis or occur in connection with syphilis or alcoholism; 
it is comparatively rare. The symptoms suggest those of the 
acute form, but they are rather moderate as to severity 
and slow in development. The pain in the back and limbs is dull 
and aching, but has the characteristic exaggeration from mo- 
tion and pressure; there may be soreness, itching and burning 
of the limbs; hyperesthesia, muscular contractions and partial 
paralysis of the legs are common; the reflexes are increased; in- 
volvement of the intestinal, vesical and sexual centres gives rise 
to incontinence of urine and fasces or constipation, and to impo- 
tency or priapism; there may be bed-sores; the presence of the 
"cincture feeling" indicates the height of the lesion. 

The most important form of Localized Chronic Spinal Men- 
ingitis is the form first described by Charcot as pachymenin- 
gitis cervicalis hypertrophica. Anatomically it consists of ex- 
tensive thickening of the dura mater in the cervical region, the 
dura appearing as though composed of concentric layers; the hy- 
pertrophy consists of a dense growth of connective tissue. The 
effects of these anatomical changes first involve the penetrating 
nerve roots, then the spinal cord, which undergoes mechanical 
compression, eventually resulting in secondary degeneration of 
the motor nerves and muscles and of the pyramidal tract in the 
cord. There is at first severe pain, shooting from the neck into 
the occiput and arms and hands (from irritation of the pos- 
terior nerve roots), continuing from two to three months; 
gradually atrophic paralysis of the upper extremities develops, 
chiefly affecting the parts supplied by the ulnar and median 
nerves, and causing contractions which give to the hand a pe- 
culiar and characteristic "claw-like" appearance. Advancing 
compression of the cord results in spastic paralysis of the 
lower extremities, with increase of tendon reflexes and without 
muscular atrophy. Finally there may be anaesthesia of the 
lower extremities, paralysis of the bladder, bed-sores, and 
death; partial recovery is possible. 

Treatment of chronic spinal meningitis consists of the exhi- 
bition of remedies suggested by careful study of the symptoms 
of the case (see Simple Meningitis, Tubercular Meningitis, 



572 DISEASES OF THE NERVOUS SYSTEM. 

Acute Spinal Meningitis), with preference for those which are 
capable of producing a profound constitutional effect. Syphi- 
litic cases may require potassium iodide and mercury. The per- 
sistent use of counter-irritation is of doubtful benefit. Abso- 
lute rest is indispensable; means of supporting the strength of 
the patient and of putting him in the most favorable surround- 
ings are important. 

AFFECTIONS OF THE BLOOD-VESSELS OF THE 

Congestion. — Practically nothing is known of hyperemia of 
the cord, from an anatomical or clinical aspect. It has been 
thought possible that neurasthenia is really the result of spinal 
hyperemia, and that in certain cases of excessive exertion, ex- 
posure, etc., with symptoms of threatening paralysis and less- 
ening of reflex activity, but stopping short of actual paralysis, 
spinal congestion is the responsible cause. It is pointed out 
that excessive functional activity of the cord is accompanied by 
congestion, as shown in cases where immoderate sexual indul- 
gence is known to have been followed by haemorrhage into the 
cord. 

Anaemia. — Equally little is known of spinal anaemia. The ex- 
periments of Herter have shown that in spinal anaemia, artifi- 
cially produced by ligating the aorta, paraplegia is soon devel- 
oped. This explains why paraplegia so often follows profuse 
haemorrhage, especialty from the uterus or stomach. 

Embolism and Thrombosis.— The former is rare; it has been 
found associated with choreiform movements. Thrombosis of 
the smaller vessels is frequent and is clearly connected, here as 
elsewhere, with endarteritis. 

Endarteritis.— This consists of the nodular peri-arteritis or 
endarteritis associated with syphilitic disease or an endarteritis 
obliterans, with great thickening of the intima and narrow- 
ing of the lumen of the vessels, usually affecting the larger ves- 
sels. 

Haemorrhage into the Spinal Cord (Haematomyelia) . — Haem- 
orrhage into the cord usually results from cold, exposure, over- 
exertion and, chiefly, traumatism. It has been noticed in con- 
nection with tetanus, convulsions, and accidents associated 



DISEASES OF THE SPINAL CORD. 573 

with rapid asphyxia. Tumors, syringomyelia and myelitis 
rarely cause it. Haemorrhage which is secondary to inflamma- 
tion or blood-disease is not included here. Haematomyelia is 
rarely recognized during life. 

Morbid Anatomy.— The cord is usually enlarged at the site of 
the haemorrhage. The extravasation is most marked in the 
gray matter, and may be focal, limited or diffuse. The white 
matter may be torn, with blood escaping beneath the meninges. 

Symptoms.— The onset is extremely sudden. A brief loss of 
consciousness or a sharp pain in the extremities is followed by 
paralysis of both arms and legs when the seat of the haemor- 
rhage is in the cervical region, of the lower half of the body 
when the bleeding is in the dorsal or lumbar region. The motor 
paralysis at once occupies its whole field and does not extend 
upward. The bladder and rectum are involved at once. There 
may be loss of sensory function corresponding to the loss of 
motor power. Myelitis frequently follows, with fever, loss of 
reflexes and decubitus. Spinal haemorrhage is nearly always 
rapidly fatal; exceptionally recovery has taken place, with 
symptoms of permanent partial paralysis. 



ACUTE AFFECTIONS OF THE SPINAL CORD. 

ACUTE MYELITIS. 

Etiology.— Acute inflammation of the substance of the 
spinal cord is a disease of early and middle life, and occurs 
oftener in men than in women. Its causes are: Exposure to 
cold, especially after overheating; soldiers during a winter cam- 
paign, after a long day's march sleeping on the wet ground or 
snow, are liable to the disease. Great exertion, leading to 
rapid loss of power; some authorities claim that excessive 
sexual indulgence, especially unnatural, belongs here. Trauma- 
tism, as fracture of the spine or injury from intense muscular 
effort. Disease of the vertebrae (caries, cancer). Infectious dis- 
eases (typhus, small-pox). Disease of the cord itself, as tu- 
mors or syphilis. Certain poisons, as phosphorus, arsenic 
lead, alcohol. 

Morbid Anatomy. — The changes which can be observed with 
the naked eye consist of softening and coloring of the cord. 



574 DISEASES OF THE NERVOUS SYSTEM. 

The former may be felt even before the membranes are opened; 
it varies in degree, and in extreme cases follows the escape of 
the broken-down matter as a pultacecus fluid. In cases not so 
far advanced, the sharp distinction between white and gray 
matter is lost, the softened areas gradually shading into nor- 
mal tissue. When the softening is most marked in the gray 
matter, it is called central myelitis; when the entire segment is 
involved transversely, it is known as transverse myelitis; when 
it is disseminated and there are foci of softened tissue here and 
there, the term insular or disseminated myelitis is applied. The 
dorsal portion of the cord shows these changes most exten- 
sively. The reddish or brownish coloring of the softened cord 
("red softening") is due to the effusion of blood from ruptured 
capillaries or larger vessels; sometimes blood-clots are found 
(hsemorrhagic myelitis). Histologically "the multipolar cells 
become irregularly swollen, with their processes broken and 
shrunken, their structure coarsely granular, or in later stages 
formless, finally broken up into debris. The nerve filaments 
first enlarge, with their axis-cylinders especially thickened; then 
they become monilif orm, and finally they break up. In the end 
the rr^elitic tissue consists of debris, with remains of nerve-cells 
and filaments mixed with drops and masses of myelin, large 
granular corpuscles, pigmented granules, altered blood corpus- 
cles, etc. Gray myelitis, so-called, is that condition in which 
there has been an attempt at recovery, with absorption of 
debris, and the formation of connective tissue passing into scle- 
rosis. Under no circumstances is there any repair of damaged 
nerve-filaments." (H. C. Wood.) 

Symptoms.— Sj^mptoms of motor irritation occur early and 
persist throughout the course of the disease. They consist of 
twitching of paretic or paralyzed muscles, first in the legs; 
ataxic movements are comparatively rare, and when they oc- 
cur are most frequent in the upper extremities. Motor par- 
alysis is first indicated by increasing weakness in the legs, cul- 
minating in complete loss of function, loss of motor power in 
the arms developing in the same manner. In transverse myeli- 
tis the paralysis involves both halves of the body; when the 
seat of the lesion is in the dorsal or lumbar portion of the cord, 
the upper extremities are not implicated. Involvement of the 
upper extremities and brachial paraplegia proves the existence 



DISEASES OF THE SPINAL CORD. 575 

of a cervical myelitis. Sensory disturbances at the onset are 
mild, and consist chiefly of formication and numbness with, 
often, very slight loss of sensibility; later, there is loss of sensi- 
tiveness of the skin, analgesia and finally, often, complete 
anaesthesia. In some cases marked hyperesthesia exists to 
painful stimuli, as the prick of a pin. The sensory disturbances 
afford valuable aid in estimating the height of the lesion in the 
cord, which is at about the level of the line of normal sensibility 
in the trunk; thus, when the seat of the lesion is in the lumbar re- 
gion,the line of normal sensibility is at the height of the navel 
or slightly above it; when in the lower dorsal region, at the 
lower end of the sternum; when in the upper dorsal, at the 
level of the axillae; when in the cervical region, the upper ex- 
tremities are involved and, rarely, anaesthesia may be complete. 
The cutaneous reflexes are diminished or lost in the lower ex- 
tremities from extensive myelitis in the lumbar region. In dor- 
sal and cervical myelitis the cutaneous reflexes are left intact 
even when there is anaesthesia, or they may be increased; ex- 
ceptionally there is impairment of cutaneous reflexes from loss 
of irritability in the conducting fibres or from irritation of the 
reflex inhibitory fibres. The cremaster reflex is lost in myeli- 
tis of the upper lumbar region. Tendon reflexes are increased 
during the state of irritation and lost after paralysis has be- 
come complete. Loss of these reflexes in the lower extremities 
indicates lumbar myelitis. When the cervical or dorsal region 
are the seat of the lesion, there may be increase of tendon re- 
flexes in the lower extremities. When the cervical region is in- 
volved, there may be increase of tendon reflexes in the upper ex- 
tremities. Disturbances in the bladder and rectum, are charac- 
teristic, and occur regardless of the seat of the lesion. More or 
less difficulty in urinating, with straining, is followed by reten- 
tion of urine from paralysis of the detrusor urinae and, later, of 
the sphincter vesicae, with incontinence. Hence the tendency in 
myelitis to the development of cystitis, which in turn may give 
rise to pyelitis and purulent pyelo-nephritis. Constipation is 
common at first; it depends upon weakened peristalsis and 
paresis of the abdominal muscles, and may be excessive. Incon- 
tinence of faeces may eventually result from paralysis of the 
sphincter ani. When there is increased reflex irritability, irrita- 
tion of the skin over the thighs, perinaeum, gluteal region, etc., 



576 DISEASES OF THE NERYOUS SYSTEM. 

may cause involuntary contractions of the bladder and expul- 
sion of urine. 

Trophic disturbances are pronounced. Muscular atrophy ap- 
pears early, with loss of electrical irritability and the reaction 
of degeneration. Often the muscles merely become flabby, show 
only slight wasting and, later, rigidity without reaction of de- 
generation; this applies particularly to myelitis below the cer- 
vical and dorsal regions. There often are trophic disturbances 
in the skin, which is dry, harsh, scaly, and occasionally covered 
with herpetic eruptions. Vaso-motor disturbances give rise to 
a mottled, cyanotic appearance of the paralyzed extremities. 
There may also be slight oedema. The paralyzed parts may be 
cold and dry, or constantly moist with sweat. Acute decubitus 
or trophic bed-sore is common; it usually appears in the sacro- 
gluteal region, much less frequently at the heels or other parts 
of the body. The skin at first presents dark erythematous 
patches, on which vesicles or bullae form within one or two 
days. Usually the epidermis drops off, exposing an angry look- 
ing surface with dark, bluish patches and bloody infiltration of 
surrounding tissue, rapidly forming a slough which may in- 
volve an extensive area and destroy all the tissues down to the 
bone. 

The seat of the lesion may be approximated if the following 
are borne in mind: Cervical myelitis: Paralysis usually com- 
plete below the seat of the lesion; rarely the arms only affected 
(cervical paraplegia). Paralysis of the upper extremities, some- 
times without involving the muscles of the shoulder. Gradual 
loss of sensation. Sometimes atrophy of single muscular re- 
gions of the arm. Slight atrophy of muscles of the legs. In- 
creased tendon reflexes and spastic symptoms in the legs, some- 
times in the arms. Normal, sometimes increased, cutaneous re- 
flexes in the legs. Often pupillary changes, vomiting, hiccough, 
great slowing of the pulse; sometimes dyspnoea and dysphagia. 
Dorsal myelitis : Upper extremities normal. Motor, later sen- 
sory, paraplegia, without degenerative atrophy. Increased 
tendon reflexes; cutaneous reflexes normal, rarely increased. 
Lumbar myelitis: Upper extremities normal. Motor, later 
sensory, paraplegia; sometimes with degenerative atropine 
Impairment or absence of cutaneous and tendon reflexes. 

Disturbances of the bladder and rectum arc present in all 
forms, regardless of the seat of the lesion. 



DISEASES OF THE SPINAL CORD. 577 

The course of acute myelitis varies greatly. In central mye- 
litis (explosive or foudroyant myelitis) the onset is sudden, al- 
most as abrupt as haemorrhage, with high fever, sometimes 
delirium, convulsions and coma; in this form the course of the 
disease may be exceedingly rapid, complete paralysis, with 
trophic changes and abolition of all the reflexes, developing 
within a few hours, and death occurring in a short time, often 
without violent constitutional symptoms. If death does not 
take place within a short time (asphyxia), it usually results in 
two or three weeks from paralytic cystitis or acute decubitus. 
In the acute form the paralysis appears in one or two weeks. 
There may be fever, headache and delirium. Death commonly 
results from exhaustion or septic fever; recovery may take 
place, but is nearly always imperfect. In the subacute form 
the course is slow and somewhat indefinite; the development of 
paralysis is tardy and incomplete; it usually terminates in 
chronic myelitis or in imperfect recovery -with paralysis and 
atrophy in groups of muscles. 

MYELITIS OF THE ANTERIOR HORNS. 
(Polio-Myelitis Anterior.— Atrophic Spinal Paralysis.) 

An acute affection, found chiefly in young children, but also 
n adults, characterized by inflammation or degeneration of the 
ganglionic cells in the anterior horns of the spinal cord, fever, 
loss of power, and rapidly developing atrophy of the affected 
muscles. It is also described as Infantile Paralysis and Essen- 
tial Paralysis of Infants. 

/Etiology —Nothing positive is known concerning the causa- 
tion of this disease. Five-sixths of all the cases occur during the 
first ten years of life, and a ma j ority of these during the first three 
years. Boys are of tener affected than girls, and more cases are ob- 
served in the summer than in the winter. Hereditary influences 
are of no importance. It is probable that exposure to cold and 
over-exertion are more frequently the cause than other condi- 
tions. It has not yet been determined to what extent trauma- 
tism is responsible for the occurrence of individual cases, but it 
is generally held of slight importance. Irritation from denti- 
tion, according to Louis Starr, is merely incidental. Epidemics 
have been observed in Europe and in America. 
37 



578 DISEASES OF THE NERVOUS SYSTEM. 

Morbid Anatomy. — The cervical and lumbar enlargements 
are the favorite seat of the affection. The disease is probably 
of arterial origin; according to Marie, embolism or thrombosis 
of the arteries cf the anterior cornua. Inflammator3' or hem- 
orrhagic processes in the anterior horns result in softening and 
disintegration, with complete or nearly complete destruction 
of the large motor and trophic cells. Later, atrophy of the 
affected half of the cord, with granular disintegration of the 
involved nerve elements. There is sometimes descending degen- 
eration in the antero-lateral column, with atrophy of corres- 
sponding nerve-roots and rapid wasting of muscles which de- 
pend for innervation upon the affected cells in the horn. The 
peripheral nerves arising from the affected herns may be exten- 
sive^ degenerated, but usually many normal elements are seen 
upon cross-section. Examination of the brain is nearly always 
negative. In some cases of long standing the corresponding 
cortical motor area has been found smaller or undeveloped. 

Symptoms.— The onset of the disease usually is gradual. 
There may be fever, for a few hours or several days, with a 
temperature ranging from 101° to 103°, sometimes with vom- 
iting, diarrhoea, delirium, and general convulsions. In some 
cases the child may retire in usual health and awaken paralyzed 
in the morning. After the initial period has passed, the paraly- 
sis is generally noticed. It usually reaches its maximum within 
twenty-four or thirty-six hours, sometimes in less time, and 
rarely requires more than three to five days. It is nearly al- 
ways localized. Sensation appears normal; pain is thought to 
be rarely experienced in the affected muscles; however, not in- 
frequently the handling of the affected member elicits from the 
child outcries, and older persons state that they suffer at this 
stage from both pain and formication. The distribution of the 
paralysis varies, but hardly ever remains as extensive as at first, 
some muscles recovering while others are permanently disa- 
bled. The face is practically exempt; the intercostal muscles 
and those of the diaphragm are hardly ever affected, a fact 
which explains the rarely fatal issue of the disease. With the 
establishment of the paralysis the fever and other constitu- 
tional symptoms pass away, and the patient appears in excel- 
lent condition, eating heartily and resting comfortably. 

For some weeks following, an improvement occurs in the ex- 



DISEASES OF THE SPINAL CORD. 579 

tent of the paralysis, groups of muscles gradually recovering 
their tone; exceptionally complete recovery takes place. All 
the affected muscles show waste and great diminution, if not 
loss, of faradic excitability. Usually, however, with marked 
improvement in some directions, certain muscles or groups of 
muscles refuse to recuperate, and in them paralysis becomes 
permanent. The permanently disabled muscles become ex- 
tremely flaccid and soon show evidence of pronounced atrophy, 
which eventually becomes extreme. This atrophy is purely de- 
generative; hence the reaction of degeneration is present. This 
consists of the following phenomena: Within two or three days 
after the onset of a paralysis there is an increasing loss of fara- 
dic and galvanic excitability in the nerve, which is completely 
lost after one or two weeks, so that muscular contraction can 
be no longer provoked by electric currents acting upon the 
nerve. At the same time the muscle itself has lost its power to 
respond to the faradic current, while after a temporary dimin- 
ution of sensitiveness to the galvanic current an increased 
sensitiveness of galvanic muscular excitability develops during 
the second week, so that weak galvanic currents applied to the 
muscle produce strong muscular contractions. These muscular 
contractions, excited by the galvanic current, are peculiar in 
that they are abnormally slow, lingering, protracted, "worm- 
like" and may persist during the entire duration of the closure of 
the current. Furthermore, they occur not only chiefly at the cath- 
odic closure, as they normally do, but at the anodic closure as 
well, and sometimes are even more marked at the latter. Often 
the mechanical irritability of the muscles is increased. This 
condition of increased galvanic muscular excitability lasts from 
four to eight weeks, when, in long-continued or incurable cases, 
it gradually passes away, so that eventually in incurable cases 
the strongest current will only produce a scarcely perceptible 
slow anodic closure contraction, and finally no contraction at 
all. The trophic changes extend also to the bones of the affected 
side or area, which become stunted in growth and, in the long 
bones, materially shortened. The skin may show trophic dis- 
turbances; it may feel cool and appear of a cyanotic color. 
The tendon reflexes are lost in the paralyzed limbs; the cutane- 
ous reflexes usually are absent; cutaneous sensibility is normal. 
Eventually the atrophied muscles may become mere fibrinous 



580 DISEASES OF THE NERVOUS SYSTEM. 

bands, and from their absolute inability to perform any of the 
functions of muscular structure, resulting in their complete re- 
laxation and in consequent separation of the articular surfaces 
of joints, serious deformities of joints may occur. Contrac- 
tions in the paralyzed part are, however, more frequent. Thus, 
the paralytic club-foot (talipes varo-equinus) and flexed thigh 
or knee are common. Great deformities arise from the contrac- 
tures of unparalyzed antagonists in the arm and spinal 
column. The distribution of permanently paralyzed muscles is 
based upon no known law. The muscles of the face escape, 
save in very rare cases. The legs are affected about three times 
as often as the arms, and the left leg is involved oftener than 
the right. Rarely both limbs on the same side are paralyzed; 
frequently it is one arm and the leg on the opposite side. In 
the arm there is more often wasting of the small muscles of the 
hand, the extensors of the wrist, and the deltoid. 

There is also described an acute or subacute polio-myelitis of 
adults which closely resembles both anterior polio-myelitis of 
children and multiple neuritis, presenting abruptness of onset, 
rapidly developing atrophy, and reaction of degeneration. It 
is unlike infantile paralysis in its continuously progressive 
course, i. e., there is no period of regression. It may begin in 
the lower extremities and extend upward, in which case death 
may occur from involvement of the muscles of respiration and 
deglutition. Most cases recover with permanent impairment 
of the muscles. 

Diagnosis. — This at the onset of the disease often is difficult, 
if not impossible. The symptoms, however, soon become un- 
mistakable; the occurrence of the affection in 3^oung children, 
the course of the paralysis and the marked trophic disturbances 
distinguish it from Landry's paralysis, while the absence of 
nerve pain with great tenderness, the completeness of the par- 
alysis, and the presence of the reaction of degeneration estab- 
lish the differentiation from peripheral neuritis. Cerebral palsy 
of children is ushered in by convulsions, but they involve one 
side or one limb, or the face, while the convulsions of infantile 
paralysis are general. 

Prognosis. — The prognosis, as to life, is very favorable; ex- 
ceptionally death may occur at the very onset of an unusually 
severe case; this passed, danger to life is ended. It is further- 



DISEASES OF THE SPINAL CORD. 581 

more safe to promise that a marked improvement will occur in 
the case as compared with the paralysis when first noticed. To 
determine the probable extent of this improvement, repeated 
and careful examinations of the susceptibility of the muscles to 
the f aradic current must be made ; any response, even though 
slight, is favorable so far as it concerns the muscles tested. 
The certainty of permanent paralysis in nearly all cases and the 
probability of secondary contractures must not only be borne 
in mind by the physician but, as a measure of self-protection, 
should be stated to the friends. If in case of paralysis of six 
months' standing intelligent treatment does not cause improve- 
ment in from four to six months, the case is hopeless. 

Treatment of Acute Myelitis and Infantile Paralysis.— In the 
treatment of myelitis absolute rest is of the greatest import- 
ance; absolute cleanliness also is imperative. Incessant care 
must be exercised to avoid bed-sores and cystitis. To accom- 
plish the former, pressure of any sort, no matter how trivial, 
must be rendered impossible. The bed-clothing, sheets, etc., 
must be kept perfectly smooth at any expense of trouble on 
part of the nurse; a water-bed is highly desirable and should be 
procured, if possible. Frequent bathing of the lower back and 
hips in alcohol is advisable; solutions of tannin and alum 
answer the same purpose. As soon as the skin breaks, the sore 
must be treated upon sound surgical principles. Danger of 
cystitis may be averted by the systematic use of the catheter, 
aided by washing out the bladder once in twenty-four hours 
with an antiseptic solution. Incontinence demands continuous 
catheterization. Spitzka suggests that the retention of the 
catheter be secured by passing it through a perforated condom 
which may be fastened to the inguinal region; to the catheter 
should be attached a tube of soft rubber which ends in a urinal. 

Venesection, the persistent use of cold (ice-bags), of the hot 
bath or hot pack (Erb), and counter- irritation by the actual 
cautery or blisters have all been recommended and in turn dis- 
carded as barbarous and worse than useless. Chapman's ice- 
bag to the spine is still used. 

In due time massage, applied persistently and by skilled 
hands, should be employed to help the wasted muscles recover 
nutrition and tone. Electricity must never be used early, and, 
according to Osier, accomplishes nothing when there is trans- 



582 DISEASES OF THE NERVOUS SYSTEM. 

verse myelitis in the dorsal region with retention of nutrition in 
the muscles of the leg. Spinal galvanization, continuous and 
sharply interrupted currents, and direct application to the af- 
fected muscles, are recommended by Rockwell. 

Infantile Paralysis. — If seen in the febrile stage, the child 
must be quietly kept in bed and under the action of such reme- 
dies as are symptomatically indicated. Blisters and counter- 
irritation of any kind are to be avoided. As soon as the condi- 
tion of the child permits, it must be taken out of doors daily, 
living in the open air as much as possible. The chief indication 
is to maintain nutrition of the affected muscles. To this end 
massage is invaluable. When that cannot be applied by skillful 
hands, frequently repeated inunctions with olive oil or cod-liver 
oil, followed by brisk rubbing of the parts, is exceedingly help- 
ful and should be maintained indefinitely, for at least many 
months daily. Electricity may be used to advantage, provided 
the task is not left to an ignorant nurse or to members of the 
patient's family. A very light faradic current may be applied 
to muscles that respond, or the galvanic current may be used, 
the poles being so placed that the muscle throughout its entire 
length is inclosed between them. It is well to have the current 
slowly interrupted or, still better, to have the current reversed, 
so as to make alternating "to and fro" currents. The use of 
electricity should not be begun too soon, but must be persevered 
in for at least three months; many muscles which at first do 
not respond, do respond later. "Its usefulness consists in 
maintaining the nourishment and normal contractility of the 
muscles which are temporarily deprived of their natural trophic 
and motor control, so that, as the inflammation subsides and 
the widespread inhibitory effect of the local lesion recedes, the 
apparatus may find the muscular periphery in the most favor- 
able state to respond to its enfeebled influence." (Starr.) Con- 
tractures must be carefully looked after. Exercise of the en- 
dangered parts is to be systematically maintained. Section of 
the tendon may afford much relief, and when performed should 
be followed by the renewed use of electricity in affected muscles.^ 
Experience has shown that the operation often at once im- 
proves the nutrition of the muscles; hence the wisdom of again 
using electric stimulation in order to aid to the fullest extent 
possible this recuperative effort. 



DISEASES OF THE SPINAL CORD. 583 

Therapeutics.— The sphere of Aconite, Belladonna and 
Gelsemdum in the initial stage is well defined by the character- 
istic concomitants. — Aconite, in addition to fever, has very 
painful anaesthesia, numbness in the hands and back, and for- 
mications. — Belladonna has tonic and clonic spasms, paraly- 
sis of the iris and muscles of the eye. — Gelsemium is indicated 
by the general paretic weakness, especially of the muscles of 
voluntary motion; incontinence of urine; paretic weakness of 
the tongue and glottis; soreness of the muscles. Confused feel- 
ing in the head. Infantile paralysis.— Mercury has been pre- 
scribed empirically and has the indorsement of many of the 
older homoeopaths, especially of the German school. Its pro- 
found action upon the nervous system, causing in the healthy 
neuralgic pains, spasmodic contractions, tremors and paraly- 
ses, speak strongly in its favor as a great remedy in serious le- 
sions of the nervous system. Hart recommends it when there 
are violent pains in the spine, worse from motion; paralysis 
and anaesthesia of the lower extremities; jerkings in the par- 
alyzed muscles; paralysis of bladder and rectum; great restless- 
ness and sleeplessness at night. Farrington states that it fol- 
lows well after Belladonna, especially in meningeal inflamma- 
tion, with hasty speech and quick nervous talking, but does 
not mention it under myelitis.— Phosphorus. In connection 
with caries of the vertebrae, with thin, offensive discharge ; in 
persons who are exhausted from sexual excesses an,d a "wear- 
ing" mode of living; numbness and insensibility of the extremi- 
ties; burning pain in the spine; cincture feeling. — Nux vomica. 
Numbness and formication along the spine ; sharp, lancinating 
pains along the spinal nerves; tonic rigidity; paralysis of the 
legs; "cincture feeling" about the waist. Strychnia, in light 
physiological doses (gr. -^ to T ^), three times daily, in cases 
that have a tendency to become chronic. — Rhus toxicoden- 
dron is useful in infantile paralysis from exposure, as lying on 
the damp ground or from over-exertion. — Dulcamara, in mye- 
litis from exposure to wet, with paralysis of the lower extremi- 
ties- — Causticum. Numbness, insensibility and paralytic weak- 
ness, with trembling from motion. Shifting, tearing pains in 
the extremities. Paralysis of hand and arms; contractures. 
Tendency to soreness in the folds of the skin. Paralytic weak- 
ness of the vesical sphincter; paralysis of the bladder; reten- 



584 DISEASES OF THE NERVOUS SYSTEM. 

tion of urine.— Secale cornutum. Paralysis of the extremities, 
with cramp, numbness and formication. Anaesthesia of the 
limbs. Tingling in the back, extending to fingers and toes; con- 
tractions of flexor muscles; paralysis of bladder and rectum. — 
Anacardium. Great debility; weariness, with restlessness; 
paralysis of single parts; sensation as of a band around the 
body. Consult also Arsenicum, Opium, Physostigma, Zin- 
cum, Oxalic acid and the remedies considered under menin- 
gitis. 

ACUTE ASCEIVOIIVO (LANDRY'S) PARALYSIS. 

An acute disease of unknown pathology, characterized by 
parakysis beginning in the lower extremities, ascending rapidly 
to the muscles of the trunk and arms, finally involving the 
muscles of respiration, deglutition and articulation, not accom- 
panied with trophic changes or changes in the electro-excita- 
bility cf the muscles. 

^Etiology.— The disease usually occurs in males from the 
twentieth to the thirty -fifth year. It may follow specific fevers, 
sometimes excessive exposure. Its pathology is unknown, no 
corresponding lesion having been found in the few cases studied. 

Symptoms. — The onset may be sudden, or there may be for 
several days general indisposition, feverishness, headache, loss 
of appetite and dragging, tearing pains in the back and ex- 
tremities. The initial symptom of the paralysis proper is a 
sensation of numbness in the legs, with rapidly increasing 
weakness which in a few hours may terminate in complete mo- 
tor parah'sis. The muscles of the trunk are involved after 
those of the legs; then the arms, neck, and the muscles of respi- 
ration, deglutition, and articulation, death usually occurring 
from failure of respiration within two or three days or, in pro- 
tracted cases, within one or two weeks. 

The muscles remain flaccid, and passive motion is easy and 
painless; there is no atrophy of muscular tissue nor are there 
constant or striking changes in the muscular electrical excita- 
bility. The reflexes may be diminished or lost; in some cases 
they appear almost normal. Sensory symptoms are variable 
and of a mild character. They consist of tingling and numbness, 
rryperaesthesia or anaesthesia. Sensation may be delayed. The 



DISEASES OF THE SPINAL CORD. 585 

sphincters are rarely affected, save, exceptionally, late in the 
disease. Sometimes the legs are slightly oed em atous. Copious 
sweating has been observed in some cases. Usually there is ab- 
sence of fever, but in the early stage the temperature may rise 
to 103° or even 104°; if so, it later nearly always drops to nor- 
mal. Moderate enlargement of the spleen, less often of the 
lymphatic gland, and slight albuminuria have been observed in 
some cases. 

The coarse of the disease is rapid. Death sometimes occurs 
within twenty-four to thirty-six hours; the duration of the af- 
fection rarely exceeds two weeks. 

The prognosis is grave, probably hopeless in the majority of 
cases. Recoveries, however, occur when the paralysis does not 
extend to the respiratory centres or "when it appears incom- 
plete; in such cases gradual improvement may occur, the mus- 
cles first attacked being the last to recover. Recovery is rarely 
complete. 

The diagnosis is not difficult, since the symptoms are striking. 

The rapid course of the disease, the absence, usually, of fever, 
and always of marked trophic changes, with the normal re- 
sponse of the muscles to electrical stimulation and the func- 
tional integrity of the sphincters, render the clinical picture 
very clear. When sensory disturbances are exceptionally 
marked, the disease may so closely resemble multiple neuritis as 
to render differentiation impossible. 

The treatment consists of absolute rest in bed, appropriate 
and nourishing diet, and the exhibition of the symptomatically 
indicated remedy. Aconite, Gelsemium, Grindelia, Rhus, 
Conium, Phosphorus, Nux vomica, Zincum and Arsenicum 
should be carefully studied. In due time massage and elec- 
tricity -will prove of serivce. 

■ CHRONIC DISEASES OF THE SPINAL CORD. 
SPASTIC PARAPLEGIA. 

A disease which is the result of sclerosis of the antero-lateral 
columns of the spinal cord, and which is characterized by loss 
of power, with spasm, of the muscles of the lower extremities, 
with exaggerated reflexes and -without pronounced sensory dis- 
turbances or trophic changes. It is also described as Lateral 



586 DISEASES OF THE NERVOUS SYSTEM. 

(or antero-lateral) Sclerosis and Spastic Spinal Paralysis. 
The essential clinical feature: loss of power associated with 
spasm, is found under conditions which differ aetiologically and 
anatomically; hence, various forms are recognized. Of these 
the most important is: 

Syphilitic Spastic Paralysis (Erb). — This occurs chiefly in 
male adults, usually at middle age, with a history of syphilis. 
Cases, however, have been observed with scarcely perceptible 
variation of symptoms when no data establishing a syphilitic 
history could be obtained; here belong cases due to exposure 
or attributed to sexual excesses, and occasionally to poisoning, 
chiefly by lead. Anatomically there is lateral sclerosis affecting 
the crossed pyramidal tract which contains the fibres that con- 
nect the spinal motor cells with the cerebral ganglia. 

Symptoms. — The first intimation of trouble consists of weak- 
ness and stiffness in the legs, occasionally with pain in the back 
or in the calves of the legs, which may show itself in more or 
less severe clonic or tonic spasms in the legs at night, especially 
after unusual fatigue, such as walking a long distance. Grad- 
ually there develops the so-called ''spastic gait." The increas- 
ing loss of power necessitates a conscious and increasing effort 
to move the leg forward and to raise it; hence the forward 
movement is slow and hesitating, while the toes drag and catch 
the ground, the body always inclining toward the leg upon 
which it rests while the other is being laboriously put for- 
ward. The spastic element is shown in the rigidity of the mus- 
cles which, with the loss of power in them, greatly shortens 
the steps and may cause trembling and rhythmical movements 
in the legs during and after walking, throwing the heels up and 
down, or preventing the natural spreading apart of the legs, so 
the knees are kept close together; spasm of the adductors may 
result in sudden and violent crossing of the legs. In some cases 
the exaggeration of the reflexes makes itself felt in walking, 
clonus developing whenever the ball of the foot rests upon the 
ground. As the case advances, the position of the patient in 
walking becomes more and more insecure; when the heel be- 
comes permanently drawn up, throwing the body forward, 
with its weight resting upon the toes, the use of canes, crutches 
and other assistance becomes indispensable. Finally the legs 
prove utterly useless, and the patient is forced to remain in the 



DISEASES OF THE SPINAL CORD. 587 

recumbent position. The legs at first are reasonably supple and 
allow passive motion, but later the development of the exag- 
geration of reflexes makes even passive motion increasingly dif- 
ficult. Eventually the patient lies with the legs extended, rigid, 
or flexed upon the thigh, with feet inverted, sometimes crossed. 
Nutrition of the affected muscle is perfect. As stated, both 
deep and superficial reflexes are highly exaggerated. In some 
cases this is so marked that violent clonic spasms are caused 
from slight touch (spinal epilepsy of Brown-Sequard) . The 
electrical reactions of the muscles are normal. In the late stage 
the muscular rigidity may be so great that no reflexes can be 
obtained. Sensory disturbances are trifling. There are no 
trophic disturbances in the joints, nor is there any loss of 
power in the bladder, rectum, or in the sexual function, save 
when the disease is far advanced. In some instances rigidity 
of the arms develops late. 

The course of the affection is steadily downward, but its 
progress is very slow, and life may not be materially shortened. 

The diagnosis is easy. 

Other forms of spastic paraplegia are: Secondary Spastic 
Paralysis, occurring as a feature of a transverse lesion of the 
cord in chronic myelitis, the result of slow compression (caries), 
pressure (tumor), or multiple sclerosis. The degree of paraly- 
sis varies; it is more liable to be complete in compression- 
myelitis, in fracture or in caries. Flaccidity of the limbs with- 
out increase in the reflexes in cases due to compression has been 
noted by French observers. Spastic Paraplegia of Infants 
(Heine's Paraplegia cerebralis spastica) is practically a birth - 
palsy (result of difficult labor), and may be due to bilateral 
meningeal haemorrhage or arrested development of the pyra- 
midal tracts. Cerebral defects (imbecility, idiocy, nystagmus) 
are not uncommon. The disease is noticed when making the 
toilet of the child or when the infant attempts to stand or 
walk. Talipes equinus is frequent. Dragging of the toes and 
cross-legged progression are observed. The ankle-clonus is 
rarely obtained. Otherwise the symptoms are those of the af- 
fection in adults. A hereditary form has been described, the 
disease occurring in several members of the same family, ap- 
pearing either in infancy or at, or after, middle age. If the 
former, there is evidence of a primary cerebral lesion (mental 



588 DISEASES OF THE NERVOUS SYSTEM. 

enfeeblement, atrophy of the optic nerve, difficult speech); in 
adults the symptoms are purely of spinal origin. 

Ataxic paraplegia, first described by Gowers, involves both 
the posterior and lateral columns. It is seen in middle life, 
oftener in men than in women, and is thought to be the result 
of cold, trauma, sexual excess and, very rarely, of syphilis. 
The symptoms combine the characteristics of spastic paraplegia 
and tabes, save that the sensory symptoms of tabes are not 
present. There is progressive weakness of the legs, with un- 
steadiness of gait, pronounced incoordination and difficulty of 
walking in the dark or with the eyes shut; this incoordination 
may involve the arms. Moderate rigidity of the legs develops 
late. There may be a dull, aching pain in the sacral region. 
Eye-symptoms are rare. The sphincters may become involved, 
and mental symptoms, like those of general paresis, may de- 
velop late. The disease runs a chronic course. 

The diagnosis rests upon the presence of symptoms of para- 
plegia and ataxia, with absence of sensory and ocular symp- 
toms. 

Primary Combined Sclerosis. — Putnam and Dana describe 
under this name certain cases in which there is chronic sclerosis 
not only of the posterior and lateral columns (chiefly pyra- 
midal tract), but of the cerebellar tract as well, accompanied 
with acute diffuse or systemic changes in the adjoining areas, 
slight degeneration in the gray matter, and involvement of the 
nerve trunks. The disease appears somewhat frequently in 
anaemic and neurotic women in the sixth decade of life. Sensory 
disturbances, as paresthesia, are followed by progressive loss 
of strength in the extremities and spastic symptoms with exag- 
gerated knee-jerk, culminating in paraplegia. The arms are 
often affected; marked mental enfeeblement may be noted late. 
The course of the disease is rather rapid. 

Treatment of spastic paraplegia demands the removal, when 
possible, of the primary disease, as syphilis (mercury; potassium 
iodide) or caries. Friction maintained for a long time, with fre- 
quently repeated and intelligently practiced flexion and exten- 
sion of the rigid muscles, is useful. Massage is always helpful. 
Much comfort may be afforded by the use of a well-fitted ap- 
paratus, which may aid the patient in getting about. At times 
orthopedic surgery can accomplish much toward giving relief, 



DISEASES OF THE SPINAL CORD. 589 

especially when there are contractures. Electricity does harm 
rather than good. The remedies most likely to be of benefit 
are those given under treatment of locomotor ataxia. 

LOCOMOTOR AXAXIA. 

A disease, dependent chiefly upon degeneration of the pos- 
terior columns of the spinal cord, characterized by loss of coor- 
dination, loss of knee-jerk, pain, and involvement of the special 
senses, especially the eye. It is also described as Tabes Dorsa- 
lis, Posterior Spinal Sclerosis, Gray Degeneration of the Pos- 
terior Columns. 

Etiology. — Locomotor ataxia is a common disease, more 
frequent in cities than in the country, occurring in men about 
ten times as often as in women, and chiefly between the age of 
thirty to forty-five years. Its specific cause has been the occa- 
sion of much debate. It is fairly well demonstrated that in the 
great majority of cases it is closely connected with syphilis, 
statistics gathered from authentic sources showing that syph- 
ilis existed in from fifty to seventy -five, and more, per cent, of 
all the cases. Struempell states "that, as a rule, in most cases 
of tabes the previous syphilis has not had a great intensity. 
Only quite infrequently do we find tertiary symptoms as well 
as tabes; we have seen, for example, severe ulcers of the skin, 
gummous periostitis, etc. The time between the infection and 
the beginning of the first symptoms of tabes varies very much; 
it may be from two to twenty years." In women, also, it is 
affirmed by competent observers, syphilis is a common aetiolog- 
ical factor, even in women of unquestioned virtue. Other possi- 
ble causes are still a matter of investigation. There is no 
reason to doubt that not infrequently locomotor ataxia occurs 
in men after severe exposure to cold and wet, as is the case 
with lumbermen; but this class of persons also furnishes many 
syphilitics, and the statistics do not show whether or not, in 
the collected cases, the question of syphilitic disease was ex- 
cluded. Great fatigue, sexual excesses and, rarely, trauma are 
thought by many to be connected with tabes; others enter a 
firm denial. It is generally admitted that alcoholism is no fac- 
tor. 

Morbid Anatomy. — The following changes take place: Thick- 



590 DISEASES OF THE NERVOUS SYSTEM. 

ening of the meninges over the posterior and lateral columns; 
they are abnormally adherent; arterio-sclerosis of blood-vessels. 
Degeneration of the peripheral nerves; often neuritis, some- 
times with muscular atrophy. Gray, atrophied appearance of 
the posterior roots of the cord and of their ganglia; degenera- 
tion of the cells of the ganglia. Sclerosis of the posterior col- 
umns, most extensive in the lumbar and dorsal regions; increase 
of connective tissue throughout the cord in advanced cases, 
often with degeneration involving the ascending antero-lateral, 
the direct cerebellar and the pyramidal tract. In the brain: 
sclerosis in the restiform bodies, inferior peduncles of the cere- 
bellum, and of certain cranial nerves (third, optic, auditory); 
cortical changes, sometimes diffuse meningo-encephalitis. The 
nature and development of the lesion is not understood. It is 
known that the sclerosis usually begins in the posterior root 
zones, the degenerative process extending upward along the 
root-zones and along the columns of Goll, but the seat of the 
primary lesion is still in the dark. Marie holds that degenera- 
tion of the spinal ganglion cells is responsible for the degenera- 
tion of the posterior root fibres and of their continuation in the 
cord, and his argument in support of this theory is, at least, 
plausible. 

Symptoms. — The initial or pre-ataxic stage is characterized 
by the appearance of fulgurating or lightning pains, usually in 
the legs, with the development of striking eye-symptoms and 
loss of knee-jerk. The eye-symptoms consist of the Argyll- 
Robertson pupil and, often, blindness from atrophy of the optic 
nerve; not infrequently one of the first complaints made by the 
patient refers to the existence of double-vision, sometimes with 
paralysis of the external muscles of the eye, chiefly the rectus. 
This stage may last indefinitely, from two to twenty years, and 
recovery may take place. The second {ataxic) stage is marked 
by a striking exaggeration of motor disturbances, of which 
the so-called ataxic gait is the most prominent, interesting sen- 
sory phenomena, the so-called tabetic crises, trophic changes 
of a grave nature, and mental deterioration. The final stage, 
the stage of paralysis, finds the patient bed-ridden, death even- 
tually occurring from some intercurrent disease, as pneumonia, 
tuberculosis, or pyelo-nephritis. 

Special Symptoms. — Sensory Disturbances —The fulgurating, 



DISEASES OE THE SPINAL CORD. 591 

lightning pains occur in at least nine-tenths of all the cases and 
usually among the earliest symptoms; not infrequently they 
persist during the greater part of the course of the disease. As 
indicated by the name, they are sharp, intense, as though made 
by a red-hot iron, coming with the swiftness of lightning, last- 
ing only a moment or two, but recurring at irregular intervals, 
which in exceptional cases are so brief as to render the pain al- 
most continuous. They somewhat resemble the severe pains of 
gout. They are usually felt in the knee or ankle, but may fol- 
low the course of a nerve. There is neither tenderness to pres- 
sure nor increase of pain from motion; sometimes hard pres- 
sure relieves; there may be a sensation of heat or burning. The 
pain is particularly severe during periods of physical depression, 
as from overdoing. There may be tingling and pricking in the 
feet, frequently with numbness, and a sense of numbness and 
formication in the region of the ulna. Often mention is made 
of the "cincture feeling" or "girdle pain" about the head, neck, 
or limbs, according to the seat of the lesion. There are areas 
of anaesthesia or of hyperesthesia. A common symptom is the 
sensation as though the patient were walking on wool, or felt, 
or velvet. Temperature sensation is usually diminished. Tac- 
tile sensation is often retarded, the prick of a pin not being felt 
for even ten, or more, seconds. Sometimes the patient cannot 
localize the pain; if a hurt is inflicted upon one foot he may feel 
it only in the other (allocheiria) or he may feel it in both feet 
or even in several places (polyaesthesia) . The muscular sense 
is materially impaired, and may be so even in the early stage of 
the disease. Complete anaesthesia of the leg, still more rarely 
of the arms, has been observed in exceptional and far-advanced 
cases, with, possibly, disturbances of sensation in the skin of 
the face, probably the result of degeneration of the sensory as- 
cending root of the trigeminus. 

Motor Disturbances.— These develop rather gradually. Some 
of them arise in part from the disturbances of sensibility and 
are not truly ataxic. Thus the inability of the patient to stand 
firmly on his feet when his eyes are shut or to walk in the dark 
are much less due to incoordination than to the loss of muscu- 
lar sense; but their presence is none the less significant. Nor 
can the patient stand steadily with his feet brought close to- 
gether and his eyes closed, or on one leg (Romberg's symptom). 



592 DISEASES OF THE NERVOUS SYSTEM. 

The characteristic incoordination is usually seen first in the 
legs; it is impossible for the patient, when lying down, to de- 
scribe a circle in the air with one foot or to touch the knee of 
one leg with the heel of the other; the movement is carried far 
out of its intended course or beyond the point designated. The 
same incoordination, intensified by the impairment of muscular 
sense, is shown in the arm, when the patient, having closed his 
eyes, is told to touch the tips of the nose or of the ear with a 
certain finger. The ataxic gait is unmistakable. The patient 
walks with his body bent forward, his eyes on the ground, the 
legs spread, and propels himself forward by a violent, jerky ef- 
fort, often raising the leg b\' a lifting of the pelvis, elevating 
the foot high, and then bringing it down to the ground with a 
stamp, as though it were a solid and lifeless mass, sometimes 
the heel first touching the ground, but oftener the entire sole of 
the foot striking at once. Not infrequently the body, in walk- 
ing, sways like a pendulum. The support of a cane soon be- 
comes necessary; after a little time two canes are needed; the 
ataxic condition finally becomes so pronounced that perfect 
helplessness results, the legs actually indulging in constant er- 
ratic and violent choreiform movements. Muscular power re- 
mains normal, as can be easily ascertained by directing the pa- 
tient to firmly grasp the hand. 

Disturbances of the Reflexes —The knee-jerk is nearly always 
lost, often very early. In connection with other symptoms, as 
fulgurating pains and ocular symptoms, it materially aids in 
the diagnosis; by itself it is of no great value, since absence of 
knee-jerk may be found in persons of good health. The skin re- 
flexes may be exaggerated at first, but later are lost. 

Disturbances of the Special Sense Organs.— The most impor- 
tant changes are in the visual organ. Ptosis often occurs 
early, single or double, with or without external strabismus. 
Sometimes diplopia is the first symptom of which the patient 
complains. Paralysis of the external muscles of the eye, in 
most cases the rectus, may be transient early in the course of 
the disease, permanent when late. Pupillary changes are 
marked. The Argyll-Robertson pupil is seen in many cases. 
The symptom consists of failure of the pupil to contract to 
bright light, while the pupillary changes incidental to accom- 
modation are perfectly normal, i. e., reflex immobility of the 



DISEASES OF THE SPINAL CORD. 593 

pupils with retained mobility on accommodation. Usually 
there is great contraction of the pupils (spinal myosis) . Optic 
atrophy with irregular contraction of the field of vision and 
disorder of the color sense—blindness to green and red first, to 
blue and yellow last — may be an early symptom. It is pro- 
gressive and terminates in total blindness. In some instances 
blindness occurs early; it is stated upon the best authority that 
in cases of blindness coming on early the ataxia is aborted or, 
rather, that the ataxic phase of the disease proceeds no farther. 
Deafness may occur from lesion of the auditory nerve. Vertigo 
is not infrequent. Involvement of the olfactory nerve is rare. 

Visceral symptoms constitute the so-called tabetic crises, 
which may be observed at any time, but not so often early in 
the course of the disease. These crises are characterized by 
paroxysms of severe pain in the organs to which they are re- 
ferred. Gastric crises occur oftener than others. They consist 
of paroxysms of intense pain in the epigastric region, usually 
accompanied with violent vomiting and copious secretion of 
hyperacid gastric juice. Their appearance is sudden and their 
duration from a few hours to several days. The vomiting is at 
times sufficiently violent to produce bleeding (coffee-ground 
vomit). In some cases the pain is centered in the umbilical re- 
gion and the symptoms are those of a violent choleraic seizure 
(intestinal crises) . Laryngeal crises are associated with severe 
spasmodic nervous cough and distressing dyspnoea, which may 
become alarming. Genito-urinary crises present symptoms 
closely resembling stone in the bladder, with agonizing, darting 
pain in the urethra, or they assume the form of intense sexual 
excitement, with frequently repeated orgasms which rapidly be- 
come painful in the extreme. Renal crises resemble renal colic. 
Muscular crises consist of great lassitude, muscular weari- 
ness and soreness, followed by transient paralysis of the affected 
muscles. With the exception of the gastric and laryngeal 
forms, these crises are rare; muscular crises are very infrequent. 

The sphincters may be involved. The flow of urine at first is 
slow and accompanied with an effort; later there may be reten- 
tion, with danger of cystitis and pyelitis. Constipation is 
common, but toward the close of the disease paralysis of the 
sphincter may supervene. The sexual power at first is normal, 
rarely increased, sometimes weakened; in the late stage it is 
lost. 

38 



594 DISEASES OF THE NERVOUS SYSTEM. 

Trophic changes may occur early; thus the fulgurating pains 
are not infrequently accompanied with herpes, oedema and 
local sweating. Alterations in the nails may be seen; also fall- 
ing out of the hair and nails. Ulcerations on the foot (on the 
heels, between the toes, beneath the big toe) are not unusual. 
They may be preceded by severe pain in the part, or there may 
be a small, dark spot under the skin which soon becomes de- 
tached or turns into a thick, horn-like mass, followed by 
sloughing and deep ulceration, usually surrounded by extensive 
infiltration of tissues. The joint affections (arthropathies of 
tabes) are of great clinical interest. They usually involve the 
knee, ankle, or hip, but may attack any joint of the body. 
There is extensive serous effusion, causing great swelling, espe- 
cially about the knee joint; the swelling is hard, pale, resistant, 
and is followed by disintegration of structures and destruction 
of bone and cartilages, causing luxations and deformities. 
Spontaneous fractures are not uncommon. Muscular atrophy 
occurs in some cases late in the disease and is not to be mis- 
taken for the effects of that general emaciation which is nearly 
always observed after the ataxic stage has well begun. Vul- 
pian has pointed out the frequency of valvular disease of the 
heart (chiefly insufficiency of the aortic valve) in locomotor 
ataxia, which probably is of trophic origin. Cerebral Symp- 
toms. Aside from the affections of cerebral nerves which have 
already been discussed, there is often a tendency to dementia 
paralytica, melancholia, imbecility, paranoia, and other forms 
of insanity Hemiplegia is occasion ally seen in connection with 
tabes; it is usually due to hemorrhagic softening. 

Course, Termination, Prognosis. — The course of locomotor 
ataxia is intensely chronic, the pre-ataxic stage alone some- 
times occupying ten, fifteen or twenty years. The case may 
never progress beyond the first stage, especially when there is 
early loss of vision. In others there is a gradual, almost im- 
perceptible, drifting into the ataxic condition, while in some in- 
stances the severe symptoms may appear suddenly and pro- 
gress rapidly. Frequently the affection remains stationary for 
a long time, or there seems to be a positive improvement, when 
an unexpected acute exacerbation ruthlessly destroys the hopes 
of the patient. In rare instances the disease runs a compara- 
tively rapid course, the paralytic stage being reached in a few 






DISEASES OF THE SPINAL CORD. 595 

months. That there is slight danger to life from ataxia is 
proved from the frequency with which patients live for fifteen 
and twenty years after they have become bed-ridden. Recov- 
ery, however, is exceedingly rare, and probably not possible. 

Diagnosis. — The early recognition of locomotor ataxia is im- 
portant and usually not difficult in the presence of the charac- 
teristic pains, absence of knee-jerk in both limbs, and the typ- 
ical ocular symptoms. When these symptoms are all present, 
the diagnosis of tabes is positive. Later, also, the symptoms 
usually are characteristic, and a diagnosis should be difficult 
only in exceptional cases and when the patient has not been 
long under observation. A differentiation between locomotor 
ataxia and General Paresis may tax the most skillful diagnos- 
tician in view of the fact that both diseases may co-exist in the 
same person. Peripheral Neuritis, by its gait, may suggest lo- 
comotor ataxia, but the gait of the former lacks wholly the 
truly ataxic element, being due not to incoordination, but to 
paralysis of the feet, which must be lifted high from the ground 
by a special and deliberate effort, so that the toes may clear 
the floor. The character of the pains also is different in neuritis; 
they are not fulgurating, and there is great soreness to pres- 
sure over the nerve-trunks. There should be no danger of con- 
founding hysterical affections (astasia and abasia) with tabes; 
in the former the pains are not fulgurating; the muscular in- 
coordination, as revealed by carefully made tests, is absent; 
the knee-jerk is rarely lost; the course of the disease is irregu- 
lar; the history of the case and concomitant symptoms suggest 
hysteria. A ready recognition of the tabetic crises, when first 
seen, cannot be expected. Their nature, however, will be un- 
derstood when the physician has become familiar with the his- 
tory of the case. The suddenness of their onset and their in- 
tensity, compared with rapid recovery of functional integrity 
of the organs affected and the absence of any lesion in them, 
will aid in placing them. The so-called "cardiac" crisis super- 
ficially resembles true angina pectoris; but the pain occurs in 
rather more prolonged paroxysms, its seat is in pr about the 
axilla on either side, does not shoot into the left arm or, when 
it does, is quite liable to dart from the left arm into the body 
and right arm. The history of the case will also help determine 
the diagnosis. 



596 DISEASES OF THE NERVOUS SYSTEM. 

Treatment. — Painstaking attention to all details of the pa- 
tient's daily life is absolutely required. He must be taught to 
avoid everything that needlessly exhausts his vitality, without, 
however, robbing him of the pleasure and profit which may be 
derived from such an occupation as he may be able to follow. 
Nothing can be more harmful than to make the patient feel 
that anything is to be gained by a wholly indolent or useless 
life. Leaving out of consideration the value of the individual 
life to society, it is yet a fact that there is no greater mistake 
than to impress an invalid with the belief that he is incapa- 
ble of a reasonable amount of serious occupation; to do so is 
to make of him a misanthrope and a crank, and to actually 
hasten that complete physical breaking-down which it is sought 
to avoid. Keep the patient usefully and pleasantly employed, 
within the limits of safety, and secure his intelligent coopera- 
tion in all measures calculated to strengthen and improve him, 
and the semi-invalid may be considered in the best possible po- 
sition for successful treatment. The things to be especially 
avoided are: physical and mental exhaustion, exposure to wet 
and cold, indulgence in alcoholic stimulants, the use of tobacco 
(except most moderate), and sexual excitement and intercourse. 
Observation has fully shown that sexual gratification materi- 
ally hastens the development of ataxic symptoms; thus blind- 
ness has rapidly followed even a moderate degree of license in 
this direction. Osier wisely insists that marriage during the 
pre-ataxic stage must be absolutely forbidden. The diet should 
be nutritious but non-stimulating; a little wine may usually be 
taken at meals. Particular attention must be paid to the diet 
of persons who have had gastric crises. 

When pain is excessive, rest in bed is indicated. Hot baths 
(Turkish baths) used at times of such suffering may afford relief; 
generally speaking, their long-continued use in ataxia is not de- 
sirable, while the tepid bath (not to exceed 86°), followed by 
brisk rubbing, may be used persistent^ and with advantage. 
During the crises, however, the hot bath and hot packs may 
render good service. Should these prove inefficient, antipj^rin, 
antifebrin, acetanilid or phenacetin may be used, and in many 
cases they act nicely. As a last resort, and as such only, hypo- 
dermic injections of morphine, with atropine, are indicated. It 
is a proof of good sense on part of the medical attendant to 



DISEASES OF THE SPINAL CORD. 597 

refuse morphia until its exhibition can no longer be safely de- 
layed. The bladder requires constant watching. It is of the 
greatest importance to prevent the presence of residual urine in 
the viscus, and the regular use of the catheter becomes an im- 
perative measure so soon as this occurs. Ammoniacal urine de- 
mands washing-out of the bladder at least every other day 
with some antiseptic solution. 

Concerning the use of electricity, claims and counter-claims 
have been made for various methods of applying it. In spite 
of strong prejudice in favor of electricity as a therapeutic 
agent, especially in the treatment of diseases of the nervous 
system, I am from personal experience and observation con- 
vinced of its worthlessness in the treatment of ataxia, save as 
it leaves upon the mind of the patient the impression that 
"something is being done." The local use of the wire-brush, 
with strong current, often relieves excessive numbness. Coun- 
ter-irritation is still advised by some authorities, but is in every 
sense worse than useless. Nerve-stretching, once warmly advo- 
cated, is no longer practiced. Treatment by suspension has 
proved disappointing and dangerous. 

In spite of the close connection between locomotor ataxia 
and syphilis, anti-syphilitic treatment here is universally ac- 
knowledged a waste of effort save in the rare cases of ataxia 
following primary infection within two years. 

Argentum nitricum. Clinically this remedy is one of the 
most important. Although first extensively employed in homoe- 
opathic practice, it has long been generally recommended. Its 
symptomatology embraces many pathognomonic symptoms of 
locomotor ataxia, as lightning pains, loss of deep reflexes, in- 
coordination of muscles, including the motor muscles of the 
eye, optic-nerve atrophy, contraction and unequal dilatation 
of pupils, girdle sensations, ataxic (tottering, irresolute) gait, 
drawing and jerking in legs and arms, etc. There is vertigo 
when he attempts to walk with his eyes closed, so he must take 
hold of things. The legs feel numb; without feeling, as 
though of wood; there are trembling and convulsive move- 
ments. It is well adapted to nervous affections connected 
with sexual excesses, and has sexual weakness to impotence. 
It has cincture feeling around the chest. It causes characteris- 
tic violent cardialgia, suggesting its use in gastric crises.— Zin- 



598 DISEASES OF THE NERVOUS SYSTEM. 

cum (Z. phosphoricum). Also used by all schools. It is of 
more value in the early stage than late. Weakness, trembling, 
unsteadiness and incoordination in the legs; formication in feet 
and legs; fulgurating pains extending to the knee; twitching of 
muscles; diplopia; strabismus; impotency; soreness and pain 
in the last dorsal vertebrae. — Phosphorus. Like Zincum, it 
acts powerfully upon the nervous system and affects the nerve- 
elements. It is indicated when there is burning, tearing pain 
along the spine and in the extremities, with formication; there 
is general exhaustion, affecting also the legs, with paralytic 
tendency rather than incoordination. Atroph}^ of the optic 
nerve, with flashes of light. Anaesthesia. Intense sexual 
erethism. Exhaustion of the vital forces and nervous affec- 
tions from sexual excesses.— Nux vomica has proved very use- 
ful, not merely as an intercurrent, as suggested by T. F. Allen, 
but in cases of great irritability of the muscular fibre, with 
much jerking and almost choreiform, violent movements. 
Numbness and easy "going to sleep" of the limbs is marked. 
In my experience it has yielded the best results when given 
highly attenuated. In two cases it acted promptly, my atten- 
tion being drawn to the remedy by the concomitant symptoms; 
in neither case was the diagnosis doubtful. In one case, that 
of a business man, a striking improvement was produced in 
five months under the action of Nux 200, which has continued 
uninterrupted for nearly as many years. — Agaricus is valuable 
in cases where during a long pre-ataxic stage there is much suf- 
fering from pain of an intense, sharp, shooting character, worse 
from exercise; cardiac crises.— Plumbum met. and Thallium 
are helpful in controlling the violent neuralgic pains. (Thal- 
lium : lancinations following each other with the rapidity of 
electric shocks.)— Arsenicum album is reported to have very 
materially helped cases of tabes with intense burning pain and 
characteristic cardialgia. — Aluminum was recommended by 
Von Bcenninghausen, who claimed to have cured with it four 
cases of ataxia. In his cases sensation as of cob-webs on the 
presface, frequent dizziness and characteristic constipation were 
ent. Soles of the feet feel swollen and too soft; numbness at 
the heels; cannot walk with his eyes shut or in the dark. 
Bruised pain in the back; pain as though a hot iron were thrust 
through the lower vertebrae.— Sec ale has caused symptoms 



DISEASES OF THE SPINAL CORD. 599 

which so strikingly resemble locomotor ataxia that this fact 
has been pointed out by writers of the dominant school; yet, its 
use by homoeopaths is neither common, nor hasit,tomy knowl- 
edge, been followed by especially satisfactory results. It has 
' 'complete inability to walk, not for want of power, but on ac- 
count of a peculiar unfitness to perform light movements with 
the limbs and hands; contraction of the lower limbs and hands; 
contraction of the lower limbs, on account of which the patient 
staggers." (Lilienthal.) 

Consult also Belladonna (in early cases difficulty in walk- 
ing on account of incoordination), Rhus (from exposure to 
wet), Gelsemium (recent cases; pains like electric shocks), Phy- 
sostigma. O'Connor claims good results from Berberis in 
the earlier stages of tabes and has had from Angustura relief 
of the fulgurant pains when all other remedies failed; he recom- 
mends Sabadilla when the pains are confined largely to the 
feet. 

HEREDITARY (FRIEDREICH'S) ATAXIA. 

Etiology. — Friedreich's ataxia is a family disease, occurring 
often in various members of the same family, but is not directly 
transmitted from parent to child. It is in all probability the 
outgrowth of a strongly developed inherited neuropathic ten- 
dency, whose expression in this particular form arises from 
causes not yet understood. Whatever increases this neuro- 
pathic tendency or weakens the vital forces, thus lessening the 
powers of resistance, aids in the development of the disease; in- 
herited syphilis, tuberculosis, a severe acute sickness or, in older 
persons, intemperate habits may therefore be counted etiolog- 
ical factors. Consanguineous marriages are also prejudicial. 
The disease occurs early in life, from fifty to sixty per cent, of 
all cases beginning prior to the tenth year. 

Morbid Anatomy. — There is extensive sclerosis of the pos- 
terior and lateral columns and of the cerebellar tract; the cere- 
brum appears not to be involved. 

Symptoms. — Distinct prodromal symptoms are rarely no- 
ticed. There is usually first awkwardness in the movements of 
the legs and arms, exceptionally simultaneous embarrassment 
of speech. Incoordination soon becomes pronounced, develop- 



600 DISEASES OF THE NERVOUS SYSTEM. 

ing a gait which may be truly ataxic, but much oftener is char- 
acterized by an irregular swaying motion, like the gait of a 
drunken person; the "stamping" of the ataxic gait is nearly 
quite absent. Romberg's symptom is occasionally observed. 
In the arms muscular incoordination leads to irregular chorei- 
form movements which are fatal to nicety of movement or del- 
icacy of execution; all the movements are overdone. Fried- 
reich's "ataxia of quiet action," which, according to this 
authority, is characteristic here and is never seen in locomotor 
ataxia, consists of inability- to hold the arm still in extension 
or in any other slightly forced position. It occurs late in the 
course of the affection and may even cause wavy or non- 
rhythmic movements of the arms and legs when at rest or of 
the ringers when the hand is quietly lying in the lap. Tremors 
and choreiform movements of the head, aggravated by excite- 
ment and sometimes involving the shoulders, also belong here. 
Disturbances of speech are common. Speech may be jerky and 
stuttering; oftener it is drawling or " scanning." In cases of 
bulbar involvement speech is rendered difficult and unintelligi- 
ble by resulting lack of control over the lips and tongue, the 
involuntary escape of saliva from the mouth, and the fibrillary 
contractions of the muscles about the mouth. Sensory symp- 
toms are trifling and consist of slight numbness, tingling and 
formication. Girdle-sensation is rarely felt. Reflexes may be 
almost normal; frequently the knee-jerk is lost; cutaneous re- 
flexes are sometimes diminished. Of ocular symptoms nystag- 
mus is the most characteristic. The oscillating movements of 
the eye may appear during near sight (Friedreich's ataxic nys- 
tagmus) or when the eye is supposed to be at rest (static nys- 
tagmus). There may be some impairment of vision, strabis- 
mus, diplopia or ptosis, but the Argyll-Robertson pupil is not 
seen. Exceptionally there is optic nerve atrophy. Trophic 
lesions are rare. Late in the course of the disease complete par- 
alysis ma} 7 supervene. Muscular contractions also are frequent 
at this time, giving rise to lateral curvature of the spine and to 
various deformities of which talipes equinus is the most impor- 
tant. There is frequently moderate dulling of the intellect, but 
rarely serious mental impairment. 

Marie described a "cerebellar heredo-ataxia" which occurs 
later in life, at about the twentieth year, with "groggy" gait, 



DISEASES OF THE SPINAL CORD. 601 

retention of knee-jerk, late spastic condition of the legs, and 
without scoliosis or club-foot. Cerebellar atrophy -was found 
in two cases. 

The course of the disease is intensely chronic, and the prog- 
nosis hopeless. Treatment is purely symptomatic and pallia- 
tive, with special care to prevent deformities. 

SYRINGOMYELIA. 

This affection consists of the formation of a cavity near the 
centre of the cord, thought to be due to the destruction of pro- 
liferated masses of neuroglia, followed by secondary inflam- 
mation, disintegration and cavity -formation. The cavity in- 
volves the substance of the posterior column and extends longi- 
tudinally, often occupying the cervical and dorsal regions, 
sometimes other portions, of the cord. In rare cases two or 
three cavities may exist at the same time. The affection usually 
begins before the thirtieth year; it is more frequent in men than 
in women. 

Symptoms.— When the cervical portion of the cord is the seat 
of the affection, as it often is, there is gradually increasing loss 
of muscular energy with atrophy of the muscles. Characteris- 
tic disturbances of sensibility show themselves. Although 
muscular sense and tactile sensation are normal, there is loss of 
the temperature sense and of the pain sense (analgesia), a con- 
dition of great importance since the patient is constantly liable 
to burn or otherwise injure himself. 

Trophic disturbances are common. The lower extremities 
usually escape for a long time, but eventually a spastic condi- 
tion supervenes, sometimes followed by paresis. Reflexes are 
increased. The special senses and sphincters are rarely in- 
volved. Arthropathies occur in about ten per cent, of the 
cases. 

The distribution of the thermo-anaesthesia varies in different 
cases and from time to time in the same individual. It may in- 
volve the entire body, skin and mucous membrane. A typical 
case gives rise to special symptoms; thus, disturbances of de- 
glutition and speech and bulbar paralysis may occur when the 
upper part of the cervical is involved. In rare cases syringo- 
myelia was discovered after death when no characteristic dis- 
turbances whatever had occurred during life. 



602 DISEASES OF THE NERVOUS SYSTEM. 

The course of the disease is tedious and the prognosis serious; 
but life may be indefinitely prolonged; the possibility of recov- 
ery has been stoutly maintained. 

The diagnosis in typical cases is easy. The presence of nor- 
mal muscular sense and of tactile sensation with temperature 
anaesthesia and analgesia are important. Anaesthetic leprosy- 
has both anaesthesia and wasting, but the trophic changes are 
much more extensive (loss of fingers and toes) and the distinc- 
tive sensory disturbances are wanting. 

Treatment consists of protection of the patient against 
burns and other forms of injury, careful watch upon possible 
cystic trouble, the use of electricity and massage to combat the 
wasting of muscles, and the exhibition of the symptomatically 
indicated remedy. French writers recommend counter-irrita- 
tion by means of the actual cautery and suspension. 

COMPRESSION MYELITIS. 

Slow compression of the cord from different causes, followed 
by interruption of its functions. 

Etiology.— The most important cause is caries of the verte- 
brae, in a very large number of cases of tubercular origin. The 
subjects are usually young persons or those in middle life. 
Caries may be of syphilitic origin; rarely it results from exten- 
sion of disease of the pharynx. Cancer of the vertebrae is a 
much less frequent cause and is usually seen in older persons; it 
may be primary or, oftener, secondary, due to extension of ma- 
lignant disease of the breast, stomach, oesophagus cr retro- 
peritoneal growths. Occasionally compression of the cord is 
due to aneurism (thoracic aorta or abdominal aorta in the 
neighborhood of the cceliac axis) or to the presence of parasites 
in the cord (echinococci cr cysticerci). 

Symptoms. — The symptoms which refer to the disease of the 
vertebrae may exist for a long time before the nerve-roots are 
involved or before actual compression of the cord occurs. 
Usually there is more or less deformity at the seat of the local 
disease, which may amount to an angular curvature, with 
sense of stiffness in the spine and pain, aggravated from touch 
and motion. When the vertebrae are eroded in the process of a 
malignant disease or aneurism, there may be no deformity, but 



DISEASES OF THE SPINAL CORD. 603 

the pain is usually severe, sometimes almost unbearable. Com- 
pression is not so much direct from the bone, as it is the result 
of dural thickening and of the presence of inflammatory 
products. It is first exerted upon the nerve-roots as they pass 
out between the vertebrae, and may give rise to severe pain fol- 
lowing the course of the nerve, of a dull, dragging, or neuralgic 
character. These pains extend into the arms and shoulders, 
lateral portions of the trunk or into the legs, according to the 
seat of the affection. In some cases no pain is felt. Formica- 
tion, numbness, and sense of coldness are frequent. 

Motor disturbances follow stiffness and weakness of the 
parts gradually progressing to paresis and complete loss of 
power, the seat of the affection determining the muscles in- 
volved. There is commonly blunting of sensibility to sensa- 
tions, especially of pain, and then scattered areas of anaes- 
thesia. Trophic disturbances do not occur in the paralyzed 
parts. In tedious cases the nutrition of the skin is materially 
affected; it becomes dry, scaly, and occasionally covered with 
eruptions; the nails become brittle; bed-sores form easily unless 
precautions are taken to avoid this complication. The nutri- 
tion of the muscles and their electrical reaction may be normal 
while their trophic centres are not involved, but atrophy of the 
muscles of the legs may occur when the point of compression is 
above the lumbar cord and the electrical reaction of the nerves 
is normal. Involvement of the lumbar region of the cord or of 
the fibres of the cauda equina necessarily results in atrophic 
paralysis of the legs, with reaction of degeneration. Involve- 
ment of the cervical portion of the cord may be followed by 
atrophic paralysis of the arms. The bladder and rectum are 
usually affected in severe cases. 

If compression be slight, the symptoms are those of mild sen- 
sory irritation and trifling paresis. With increasing compres- 
sion the symptoms become more serious; disturbances of sensi- 
bility are marked and the paresis increases to complete loss of 
power, accompanied with vesical and other disturbances which 
belong to this condition. In some instances the primary disease 
may exist for a long time before compression-symptoms appear, 
and the latter may even then be so mild as to cause little 
trouble; in others the spinal symptoms may assume a serious 



604 DISEASES OF THE NERVOUS SYSTEM. 

aspect from the beginning and wholly overshadow the primary 
affection. 

As has been intimated, the seat of the compression determines 
the nature of the spinal symptoms. Reference to the "Focal 
Lesions in the Spinal Cord" at the beginning of this section 
will be sufficient to elucidate these. 

The course and prognosis depend upon the nature of the pri- 
mary disease. Recovery is out of question in the presence of 
malignant disease. When the primary cause comes within the 
reach of successful treatment, it is possible that permanent relief 
and even complete cuie of the pressure paralysis may be 
brought about, except in cases where there is constitutional 
tuberculosis, which in itself may terminate life, or where a pro- 
found^ cachectic state precludes permanent improvement, or 
where cystitis, bed-sores or other complications have arisen 
and bar the way to recovery. 

The diagnosis is easy when the local disease can be recog- 
nized. To this end, in a case which at first seems obscure, dili- 
gent search must be made for evidence of local pain and tender- 
ness on pressure and for such trifling deformities as might 
easily escape attention. It must be remembered that often in 
caries the local symptoms are surprisingly slight; when such is 
the case, the diagnosis rests upon the symptoms caused by 
pressure upon the nerve-roots, as shown in slight sensory irri- 
tation, motor paralysis, and in considerable abnormalities of 
sensibility. Persistent lumbago is frequently present in Pott's 
disease, especialh- from injury. Malignant disease may be sus- 
pected when the pain is intense ( paraplegia dolorosa) , when the 
history of the case shows the previous existence of cancerous 
growths (especially cancer of the breast, with operation), or 
when nodules in the breast or suspicious enlargement of lym- 
phatics are present and when there is marked cachexia. The 
pain experienced from compression due to erosion b\^ retroperi- 
toneal growths is agonizing. 

Treatment.— The treatment is largely surgical and includes 
"extension" which, properly practiced, has given excellent re- 
sults in Pott's disease. Constitutional treatment, as of tuber- 
culosis, is important when indications for it exist. The value 
of remedies like Arsenic, Aurum, Silica, Sulphur, and others, 
suggested by the presence of caries, is apparent. Massage and 
electricity exert a favorable effect upon the paralyzed muscles. 



DISEASES OF THE SPINAL CORD. 605 

LESIONS OF THE CAUDA EQUINA AND CONUS 
MEDULLARIS. 

These result from injury (fracture), caries or tumor at or be- 
low the level of the second lumbar vertebra. In a number of 
cases injury to the cauda equina was followed by paralysis of 
the bladder and rectum alone, with, sometimes, anaesthesia in 
the neighborhood of the coccyx or perinaeum, limited to a small 
area. When branches of the lumbar or sacral nerve-roots are 
involved, as is usually the case, an irregularly distributed 
motor and sensory paralysis in the legs results. Compression 
of lumbar nerve-roots, from the second to the fifth, causes par- 
alysis of the muscles of the legs excepting the flexors of the 
ankles, the peronaei, long flexors of the toes and the intrinsic 
muscles of the feet, with loss of sensation of the inner surface 
of thighs, legs and feet and of the outer part of the thighs. In 
a case of involvement of the sacral roots alone, reported by 
Osier, seen sixteen years after the injury, " there was slight 
weakness with wasting of the left leg; there was complete loss 
of the function in the ano-vesical and genital centres, and anaes- 
thesia in a strip at the back part of the thigh (in the distribu- 
tion of the small sciatic), and of the perinaeum, scrotum, and 
penis. The urethra was also sensitive." 

TUMORS OF THE SPINAL CORD AND ITS 
MEMBRANES. 

Tumors occur oftener in the meninges than in the cord. 
Fibromatous, sarcomatous, tuberculous and syphilitic growths 
are observed on the dura; tuberculous, syphilitic and glioma- 
tous growths in the cord. 

The symptoms are those of compression of the cord and 
nerve roots, differing in character and intensity with the size 
and position of the tumor, the rapidity of its growth, and the 
degree of inflammatory action caused by it. When in the dura, 
the resulting compression is slow and progressive. When 
within the cord, it may cause syringomyelia, sometimes my- 
elitis. There may be ascending and descending degeneration. 
Loss of motion and sensation are prominent. A small tumor 



606 DISEASES OF THE NERVOUS SYSTEM. 

may at first only affect one-half of the cord, in which case there 
is motor and sensory monoplegia. The reflexes are first in- 
creased, then lost. If the tumor be in the dorsal region, the re- 
flexes in the legs are retained. Trophic disturbances only occur 
from secondary lesions of the cord. The so-called "root-symp- 
toms" consist of pain, paralysis and atrophy of muscles, mus- 
cular contractures, and change of electro-muscular contrac- 
tility. The pain is sharp, lancinating, clawing, usually intense, 
and arises from the irritation of the nerve roots by inflamma- 
tory action. It may be constant or occur in paroxysms, follows 
the nerve trunk throughout its course, and is associated with 
keen, girdle-sensations. Finally there is complete anaesthesia 
without lessening of the pain (anaesthesia dolorosa) . Cancer- 
ous tumors usually give rise to intense suffering. 

The diagnosis is uncertain. Spinal tumor is suggested by the 
intensity of the pain; the simultaneous occurrence of motor 
and sensory paralysis; the absence of trophic changes save as 
there is secondary lesion of the cord; the unilateral character 
of the paralysis when the tumor is small; the abrupt limitation 
of the paralysis; and occasional marked improvement or 
change for the worse, possibly due to change in fullness of 
the vessels or to haemorrhages in the substance of the tumor 
(Struempell). Transverse myelitis from spinal caries presents 
man}' similar symptoms. The pain here, however, is not 
nearly so severe, except as there may be inflammation about 
the nerve-roots; in the absence of such inflammation the pain 
is dull, gnawing, boring, especially when in the back; there is 
also tenderness upon pressure over the diseased vertebrae. 

The prognosis is unfavorable. 

The treatment is symptomatic and unsatisfactory, except 
that in some cases of syphilitic origin specific treatment may 
prove successful. Surgical methods, though full of risk here, 
may be justified as a last resort. 

PROGRESSIVE SPINAL MUSCULAR ATROPHY. 

A chronic disease due to slowly degenerative changes of 
trophic or motor centres in the cord (or medulla), character- 
ized by slowly progressing atrophy, with loss of power of cor- 
responding muscles or groups of muscles. That form in which 



DISEASES OF THE SPINAL CORD. 607 

the seat of the affection is in the medulla will be considered sep- 
arately (see Bulbar Paralysis). The forms here considered are 
Progressive Muscular Atrophy and Amyotrophic Lateral Scle- 
rosis, also known as Wasting- Palsy, Cruveilhier 's Palsy, Aran- 
Duchenne type of Progressive Muscular Atrophy, Poliomyeli- 
tis Anterior Chronica. 

^Etiology. — Nothing positive is known of the causes of this 
affection. In some cases (amyotrophic form) it seems a feature 
of senile degeneration. It is rare before the thirtieth year of 
life (progressive muscular atrophy in those younger is usually 
due to disease of the muscles), and more frequently attacks men 
than women. Heredity is a factor in some cases. 

Morbid Anatomy. — The essential feature is slow degeneration 
of the motor paths, involving particularly the nerve cells of the 
anterior horns and the anterior root-fibres. The following 
changes occur: Muscles. Narrowing of the fibres, fatty and vit- 
reous degeneration, longitudinal splitting-up of the fibres, with 
eventual destruction of fibres. Peripheral nerves. Degenera- 
tion and destruction of the nerve-filaments, first and chiefly af- 
fecting the anterior roots. Cord. Atrophy and, in places, disap- 
pearance of the large ganglion cells in the anterior cornua, with 
increase of the neurogliar tissue. Often sclerosis in the antero- 
lateral tracts, leaving the direct cerebellar and antero-lateral 
ascending tracts normal (Charcot's amyotrophic lateral scle- 
rosis). Degenerative changes of medullary gray matter, some- 
times with wasting of motor nuclei. Degeneration in the pyra- 
midal tracts through the pons and capsule and wasting of 
large ganglion cells in the motor cortex. 

Symptoms. — The onset of the disease may be very slow, al- 
most imperceptible. The patient may suffer from pains of a 
character that suggests rheumatism, followed in due time by 
some loss of muscular energy, with only flaccidity or, later, 
slight wasting of the weak muscles. In some cases sluggish 
fibrillary contractions in different parts of the belly of a muscle 
occur at this stage and are indicative of danger to the struct- 
ural integrity of the affected fibres; exceptionally, in rapidly 
progressing cases, these fibrillary contractions are very active 
and a source of great torment. 

The hands are nearly always first affected. According to 
some observers, the interossei are first implicated; others main- 



608 DISEASES OF THE NERVOUS SYSTEM. 

tain that the first change is atrophy of the muscles of the ball 
of the thumb. In all cases the muscles of the ball of the thumb, 
interossei and lumbricales are affected early, and the atrophy 
of these muscles, with contraction of the flexors and extensors, 
produces the striking deformity known as claw-like hand (main 
de grille; Duchenne) which is so commonly seen in muscular 
atrophy. Other portions of the body become involved and 
may be attacked before the hands or arms. In the forearms 
the flexors are usually involved before the extensors; in the 
shoulder-girdle the deltoid suffers first; or the pectoralis major, 
the serratus magnus or possibly the lumbar muscles are in- 
volved early. Of the trunk-muscles the trapezius is usually the 
last to be affected. When the disease begins in the legs, the 
glutei, vasti, and tibialis anticus are involved first. In nearly 
all cases there is a rough symmetry of wasting, though the cor- 
responding muscles on both sides of the body may not be af- 
fected evenly. The muscles of the face escape until late. Even- 
tually, from general atrophy of the muscles, the patient 
becomes to all intents and purposes a living skeleton. Deform- 
ities are frequent from loss of power in certain muscles and 
contractures in their antagonists; mere loss of power may give 
rise to serious inconvenience, as the inability to hold up the 
hand, and to subluxation by elongation of ligaments (as in the 
shoulder-joint). There may be coldness and numbness of the 
affected limbs, with normal sensation; the muscles respond less 
and less energetically to electrical stimulation, and finally cease 
to respond, first, to the faradic, then to the galvanic, current; 
the reaction of degeneration is said to be present in advanced 
cases, but its existence is called into question by some ob- 
servers. After muscular excitability has been lost, the nerve- 
trunks may still respond to the electrical stimulation. H. C. 
Wood states that in cases where the fibrillary contractions of 
the muscular fibre are very severe, an abnormal readiness to re- 
spond to the faradic current may be seen. The reflexes in the 
affected muscles are eventually diminished or lost. 

The amyotrophic lateral sclerosis of Charcot has wasting of 
muscles with loss of power, characterized by spastic contrac- 
tions and heightened reflexes (even to jaw-clonus) not ob- 
served in the other forms. The extremities may be affected 
first or the disease may involve arms and legs simultaneously. 



DISEASES OF THE SPINAL CORD. 609 

Trophic symptoms may predominate in the arms and spastic 
symptoms in the legs. The " spastic gait" is usually marked. 
Wasting of muscles is not as great as in the atonic form above 
described. Sexual power may be lost early. In this form ex- 
tension of the disease upward, with symptoms of glosso-labial 
paralysis, is frequent, often followed by tremors, failure of 
memory, and dementia. 

Diagnosis.— There is usually no difficulty in recognizing this 
affection, although the progressive muscular atrophy of myo- 
pathic origin presents many similar symptoms. However, 
the lateral affection is peculiar to young people, begins very 
rarely in the hands, but in the muscles of the shoulder-girdle or 
in the peroneal group, is a disease of early childhood and a 
family affection. 

The course is chronic and shortened by extension upward. 

The prognosis is hopeless. 

Treatment consists of vain attempts to arrest the progress 
of the degenerative process by the exhibition of Arsenic, 
Strychnia, or Plumbum, or the employment of massage. 



BULBAR PARALYSIS (GLOSSO-LABIO-LARYNGEAL 
PARALYSIS). 

An affection involving the motor nuclei of the medulla ob- 
longata. It may occur as a primary affection, but usually is 
incidental to degeneration of the nuclei of the motor path. It 
may be acute or chronic. 

Acute (Apoplectiform) Bulbar Paralysis is rare; it results 
from haemorrhage into the pons or medulla; also from embolic 
softening; more rarely from inflammatory softening, as after 
certain fevers. The affection is sudden in its onset, and is rec- 
ognized by the rapid loss of speech and swallowing; paralysis 
of the laryngeal muscles is frequent. The affection nearly al- 
ways proves rapidly fatal, but exceptionally recovery may oc- 
cur. There may be monoplegia or alternate hemiplegia with 
paralysis on one side of the face and on the other side of the 
body. 

Chronic Bulbar Paralysis.— The symptoms develop very grad- 
ually. There is difficulty in articulating, at first in pronounc- 
39 



610 DISEASES OF THE NERVOUS SYSTEM. 

ing dentals and Unguals (alalia or anarthria). The tongue 
soon becomes visibly atrophied, flabby, thin, flat; it looks fur- 
rowed and depressed; there may be fibrillary twitchings of 
muscular fibres in the tongue. Loss of power follows atrophy 
and is in proportion to the fibres wasted. Eventually the 
tongue lies limp and flat on the floor of the mouth, interfering 
with speech, chewing and swallowing. In the meantime the 
muscles of the lips are invaded. There is first a sensation of 
stiffness and awkwardness in the lips; after a time it is found 
difficult, and then impossible, to purse the lips and to pro- 
nounce the letters O, P, F, B, and others, or to whistle. Later 
the lips become thin and sharp; fibrillary twitchings may also 
be felt in them. The muscles of expression, supplied by the lower 
division of the facial nerve, are now affected; hence the charac- 
teristic face of bulbar-paralysis, the half-open and wide mouth, 
with drooling, the flabby, drooping lower lip, deep naso-labial 
folds, and the stupid lachrymose expression of the countenance. 
The involvement of the pharyngeal and laryngeal muscles still 
further increases these troubles and the danger of the patient. 
Paresis of the soft palate adds to the difficulty of swallow- 
ing, and there is frequent regurgitation of liquids through the 
nose. The voice becomes nasal. Involvement of the laryngeal 
muscles prevents the natural modulations of the voice. Imper- 
fect working of the arytenoid cartilages allows food to enter 
the larynx, exciting bronchitis or pneumonia. Paralysis of the 
vocal cords gives rise to aphonia. Severe dyspnoea may be 
caused by inability to cough and to get relief from the accumu- 
lation of mucus in the throat. 

Emaciation is unavoidable. The reflexes are diminished or 
lost, so that gagging can no longer be excited by tickling the 
fauces. Sometimes there is exaggeration of reflexes (jaw- 
clonus). Exceptionally the muscles in the region supplied by 
the motor branch of the trigeminus may be involved, and there 
may be ptosis or strabismus irom involvement of the ocular 
muscles. Sensation remains intact throughout. 

Occasionally there is complaint of heat and "boiling" in the 
head. The salivary secretion seems to be actually increased. 
The pulse toward the close frequently becomes rapid. The 
mind remains clear, but there may be great emotional activity. 
Death results from inanition, pulmonary complications (bron- 



DISEASES OF THE NERYES. 611 

chitis, aspiration pneumonia, pulmonary gangrene) and from 
failure of the respiratory centres; sometimes there is fatal 
choking while attempting to eat. The duration of the disease 
usually covers from two to five years, with occasional periods 
of improvement. 

Treatment promises little, if any, permanent help. Plum- 
bum, Arsenicum, Argentum nitricum, Phosphorus and pos- 
sibly Strychnia should be of some service. Electricity may 
aid in maintaining for a considerable length of time the integ- 
rity of special muscles. The stomach tube must be used for 
purposes of feeding the patient as soon as deglutition is seri- 
ously interfered with, but it must be introduced and manipu- 
lated with great care to avoid injuring the parts. In many 
cases rectal alimentation is preferable. 



DISEASES OF THE NERVES. 

NEURITIS. 

Inflammation of the nerve-fibres may be localized or multiple; 
of the latter, several types are recognized. 

LOCALIZED NEURITIS. 

Etiology. — A very common form is the result of cold (rheu- 
matic neuritis), usually exposure to a draught of air; it is seen 
often in the facial, sometimes in the sciatic, nerve. Frequent 
causes are: Injury, as from fracture, wounds or bruising of the 
nerve, as in the neuritis which occasionally follows child-birth 
from injury to the pelvic nerves by pressure from the fcetal head 
or forceps. Extension of inflammation from neighboring parts, 
chiefly disease of the bones, as in spinal caries or otitis media, 
syphilitic disease, malignant tumors. Localized neuritis may 
also occur in connection with diseases of the joints (especially 
of hip, shoulder, knee) or, rarely, from the action of certain 
poisons. 

Morbid Anatomy. — The nerve trunk is swollen and thickened. 
The nerve-sheath is reddened and infiltrated. The infiltration 
of round cells into the sheaths and interstitial tissues may be 



612 DISEASES OF THE NERVOUS SYSTEM. 

sufficient to appear as purulent neuritis; this is common in cases 
due to inflammation from diseased bone. In mild cases the 
nerve fibres may present no visible changes, but in severe cases 
there is disintegration of the sheaths and axis cylinders, and 
finally destruction of the fibres, in part due to pressure exerted 
upon them by the surrounding exudation and structures. Re- 
generation of peripheral nerves is often accomplished. 

Symptoms. — There is pain in the inflamed nerve-trunks and 
in the region of their distribution, not infrequently extending 
beyond. The pain is burning, shooting, stabbing, persistent, 
with periods of intense exacerbation; it is always exaggerated 
by pressure over the affected nerve and by active or passive 
movement. It is associated with numbness and tingling. 
There may be pronounced hyperesthesia, followed by loss of 
sensibility. Disturbances of motion consist of twitching, spas- 
modic contractions, impairment of motion, and even complete 
loss of power. In mild cases electrical reactions are not mate- 
rially affected; in severe cases there may be reaction of degen- 
eration. Trophic changes may be marked. The temperature 
of the affected part is frequently elevated, the skin may be red- 
dened, and there may be local sweating. Often the skin is 
''glossy," the surface appearing perfectly smooth, shiny and 
"silky," without the natural lines and creases. Eczematous 
and herpetic eruptions are common; herpes zoster and arthritis 
occur in exceptional cases. The inflammatory action may, 
rarely, ascend the nerve-trunk and, according to Gowers, even 
reach the spinal cord and set up a subacute or chronic myelitis. 

The duration of an attack is a week, or more; the neuritis 
may, however, become chronic, and then leads to atrophy of 
the muscles and to trophic changes involving the skin, finger- 
nails and joints. 

MULTIPLE NEURITIS (Peripheral Neuritis. -Polyneuritis). 

Multiple neuritis presents an exceedingly complex picture, 
leaving the conviction that its essential symptoms must arise 
from systemic poisoning of some kind, modified in individual 
types by some peculiarity in the action of the responsible toxic 
agent and by the environments and idiosyncrasy of the pa- 
tient. ^Etiological^, Osier recognizes the following types: 

The Idiopathic form, the result of exposure or exertion. The 



DISEASES OE THE NERVES. 613 

toxic form, caused by (a) diffusible stimulants (alcohol, carbon 
monoxide, carbon bisulphide, etc.); (b) metallic poisons' (lead, 
arsenic, mercury, phosphorus); (c) animal poisons (diph- 
theria, typhus and other fevers, syphilis, tubercle, malaria, 
leprosy); (d) vegetable poisons (ergot, morphine, etc.); (e) en- 
dogenous poisons (rheumatism, gout, arthritis, diabetes, the 
puerperal state, chorea (?).) The dyscrasic form (cancer, 
anaemia, marasmus) . Endemic neuritis or beri-beri. — Parenchy- 
matous neuritis may be a late complication, and at times a 
precursor, of central disease, especially of locomotor ataxia. 

Morbid Anatomy. — The lesions are those of localized neuritis, 
with the degenerative changes more marked at and near the 
periphery. When interstitial changes exist with the parenchy- 
matous degeneration, they are more pronounced in the larger 
nerve-trunks. 

Symptoms. — The beginning of a severe acute multiple neuritis 
is not unlike that of an acute infectious fever, consisting of a 
chill, prostration and fever, with a temperature ranging from 
102° to 104°, often accompanied with malaise, headache, and 
possibly slight delirium. Pains are present, nearly always, 
from the very onset. They are pulling, tearing, burning, "ful- 
gurating" pains, following the course of the nerves, usually 
with tingling, numbness, paresthesia and hyperesthesia. 
Loss of power develops simultaneously, usually first in the ex- 
tremities, especially in the hands, arms, and upper leg; in ex- 
ceedingly severe cases all the extremities may be involved at 
once. Frequently the legs are ataxic rather than paralyzed. 
Hyperesthesia now changes into a loss of sensibility, with ex- 
cessive sense of pain and soreness in the skin and deeper tissues; 
if the nerves of the trunk are involved, there is marked girdle 
sensation. The tendency of the paralysis is toward the trunk; 
in very severe cases there may be involvement of the nerves of 
special sense, causing loss of sight, hearing and smell, and of 
the oculo-mctor nerves, giving rise to double vision and irreg- 
ular pupils, followed by symptoms of bulbar disturbance and 
death from paralysis of the muscles of respiration. All the re- 
flexes are usually diminished and may cease entirely. Electric 
excitability of affected muscles and nerves is generally lost, and 
there is the reaction of degeneration. Muscular atrophy occurs 
early and is pronounced. The pulse usually is rapid. The func- 



614 DISEASES OF THE NERVOUS SYSTEM. 

tions of the bladder and rectum, with rare exceptions, remain 
normal. Trophic disturbances are frequent and consist chiefly 
of pigmentation and thickening of the skin, eczematous erup- 
tions, oedema and bed-sores; the hair and nails are also in- 
volved. 

In cases which assume a chronic form the symptoms of inva- 
sion are much more moderate, and there develops an extensive 
atrophic paralysis, chiefly in the lower extremities, but often in 
the arms as well, with loss of reflexes and only slight sensory 
disturbances; the sphincters are rarely involved. Muscular in- 
coordination may precede loss of power. In some of these 
cases there are marked psychical disturbances, with enfeeblement 
of memory and intellect. Here, also, the disease may gradually 
progress to a fatal termination, or a complete or partial recovery 
may eventually take place. The nerves least liable to be attacked 
are the hypoglossal, the spinal accessory, the glossopharyn- 
geal and the nerves of special sense. Variations from the 
course outlined are, however, very great, as will be seen from 
a description of the following types: 

Alcoholic Neuritis. — This occurs oftener in women than in 
men and is generally slow of development; the premonitory 
symptoms often escape attention. Sensor} symptoms appear 
first, consisting of numbness and tingling, pain resembling neu- 
ralgia, and frequently quite severe cramping. There is usually 
hyperesthesia of the skin; more rarely areas of anaesthesia. 
The hands and feet are cold, discolored in blotches, somewhat 
swollen, and in women "glossy skin" is often seen on the hands 
and feet. Paralysis usually begins in the lower extremities, but 
frequently appears simultaneously in the hands and feet, pref- 
erably in the extensors, causing wrist-drop and foot-drop. The 
muscles are soft and waste rapidly; there is loss of the super- 
ficial and deep reflexes, and reaction of degeneration. The 
muscles of the face and the sphincters generally escape, but the 
involvement of the extremities may be complete. A marked 
feature of this t} r pe is the presence of cerebral disturbance, con- 
sisting of delirium, hallucinations, mania, melancholia and even 
dementia. The cerebral symptoms are undoubtedly the result 
of alcoholism, and not of neuritis, but their diagnostic import- 
ance renders them of value. The course of the disease is com- 
paratively slow, although death may occur in a few days from 



DISEASES OF THE NERVES. 615 

paralysis of the muscles of respiration. In tedious cases, con- 
tractures and deformities, especially of the lower limbs, are not 
infrequent. (See also " Alcoholism.") 

Post-Febrile Neuritis. — These types occur during convales- 
cence from, or in the course of, fevers and constitutional dis- 
eases. The neuritis following the exanthemata, especially 
small-pox, usually affects the legs, sometimes both, again only 
one. Great muscular wasting may be present. There is com- 
paratively slight pain. Diphtheritic neuritis involves the heart, 
palate and eyes or, when general, the nerves of the extremities. 
It is of particular interest to the general practitioner because of 
the frequency with which it occurs and the gravity of it as a 
complication. In diabetic neuritis there are marked trophic 
changes, and pain may be excessive. A neuritis occurs in con- 
nection with leprosy, characterized by extensive trophic 
changes and anaesthesia. The form which is a feature of 
senility usually attacks the lower limbs, especially the calves; 
the sensory disturbances are more prominent than the motor. 
The neuritis from arsenical or lead-poisoning is discussed more 
fully under "Intoxications." 

Endemic Neuritis or Beri-Beri. —Beri-heri is found chiefly in 
the tropics (Japan, in the West and East Indies, some parts of 
Africa, Cuba, etc.). A disease closely resembling it has been 
observed among New England fishermen following their occu- 
pation on the coast of Newfoundland. 

Etiology. — The various causes assigned are: ankylostomia- 
sis, a diet composed largely of fish (decomposed fish), and an 
exclusive vegetable diet, chiefly rice. So far as the latter is con- 
cerned, it is a notable fact that in the Japanese navy, in which 
beri-beri has long extensively prevailed, a remarkable improve- 
ment soon followed the adoption of a more varied and hearty 
diet and the substitution of wheat for rice. The prominence of 
general constitutional symptoms which cannot be considered 
due to the affection of the nerves has led observers to search 
for a constitutional cause not yet recognized; of late, a specific 
micrococcus has been found, which is at present the subject of 
special study. Beri-beri attacks chiefly young men in over- 
crowded quarters and prevails during the hot season. 

Symptoms. — Light cases are characterized by numbness, 
more or less pain, slight oedematous swelling, malaise, weak- 



616 DISEASES OF THE NERVOUS SYSTEM. 

ness, anaemia with cardiac irritability and innutrition. In 
severer cases there is great loss of power in the arms and legs, 
which may involve the trunk and face, with rapid wasting of 
the muscles and reaction of degeneration. In some instances 
the oedema is marked, and effusion into the serous sacs (gen- 
eral anasarca) gives to them a distinct type (the "wet" type); 
in others, serious constitutional symptoms (vomiting, diarrhoea, 
enfeebled circulation, urinary suppression) overshadow the 
symptoms of neuritis, and death from heart-failure may occur 
in a few days ("pernicious" type). 

Prognosis. — As stated in the beginning, regeneration of nerve 
tissues may be successfully accomplished even in serious cases; 
hence the prognosis of multiple neuritis is really more favorable 
than would at first glance appear. If the muscles of respira- 
tion escape, and their involvement is a feature principally of 
cases which from the start progress very rapidly, then recov- 
ery is the rule; but often this recovery is incomplete. In alco- 
holic neuritis death may occur as the result of complications 
due to alcoholism. 

Diagnosis.— The diagnosis of multiple neuritis is not difficult. 
In many respects it resembles Landry' s paralysis or acute poli- 
omyelitis, but may be distinguished by the more deliberate de- 
velopment of the paralysis, the comparative symmetry of its 
distribution at the onset, and the tenderness over the nerve 
trunk. From locomotor ataxia it differs in the absence of 
Romberg's symptom, in the absence of incoordination, either 
entirely or nearly so, and in its gait, the gait of neuritis con- 
sisting of a deliberate lifting of the leg high to avoid catching 
the toe on the ground (steppage gait of Charcot), while that of 
ataxia is jerky and stamping. (See "Ataxia"). Tenderness 
over the nerve trunk is of great diagnostic value. 

Treatment.— Perfect rest in bed is essential; if the case is se- 
vere, a water-bed is both a necessity and a luxury; the diet 
must be plain, nourishing, non-stimulating. To relieve pain, 
hot applications should be perseveringly tried in the form of 
cloths wrung out of hot water and frequently changed, hot 
water-bags or "Japanese stoves" or boxes; the latter are light 
and convenient, and can be purchased in all larger towns. In 
view of possible anaesthesia, care must be taken not to scald or 
burn the patient. If hot applications are not well borne or fail 



DISEASES OE THE NERVES. 617 

to give relief, ice may be tried. The thermocautery, lightly ap- 
plied along the nerve trunks, often acts well; chloroform lini- 
ment sometimes is soothing. If all these fail, recourse may, in 
case of great suffering, be had to acetanilid, anti-febrin or 
antipyrine, taking due precaution not to give large doses until 
the patient's ability to bear these substances has been ascer- 
tained by actual experiment with small doses. Morphia, hypo- 
dermically, should only be employed as a last resort. Some- 
times the patient complains of coldness in the affected extrem- 
ities; in that case they may be wrapped in cotton-wool. In 
alcoholic neuritis generous feeding is important; the rules given 
under "Alcoholism" should be followed out. After the acute 
stage has passed, massage, properly given, is exceedingly use- 
ful. The galvanic current may also be employed at this time, 
but never early in the case; the positive pole should be placed 
over the seat of pain, the negative pole over the spinal origin 
of the affected nerve or at the periphery. The sittings should 
be daily, and not more than five to ten minutes. Shocks and 
interruptions must be carefully avoided. Muscular atrophy 
calls for massage and the interrupted galvanic current. 

Aconite is beyond doubt of great value, not only in recent 
cases, or in cases arising from exposure to cold or with charac- 
teristic fever, or in localized neuritis, but often after the case 
has continued for some time, provided there is tense, drawing 
pain, with unbearable numbness and formication and a feeling 
as though the affected parts were "asleep;" there is also red- 
ness and heat of the affected parts.— Belladonna has excru- 
ciating pain, drawing, pressing, cramping, tearing, throbbing, 
from the periphery to the centre, often with bright redness of 
the surface, and with a perfect horror of having the parts 
touched, on account of their exquisite sensitiveness.— Arsen- 
icum. Of inestimable value in the neuritis of persons who are 
exhausted from anaemia or a tedious fever, or when neuritis oc- 
curs as a feature of alcoholism, or as the result of marasmus 
or cachexia (malignant disease). The indications are clear-cut 
and unmistakable. Motor paralysis is pronounced. The pain 
is burning and intense, with great anxious restlessness and 
prostration. Relief from external heat.— Rhus toxicoden- 
dron. Of service when neuritis occurs as the result of exposure 
from getting wet; it is frequently indicated in sea-faring men who 



618 DISEASES OF THE NERVOUS SYSTEM. 

have passed through a prolonged storm, drinking heavily and 
standing in water a good part of the time. The paralytic symp- 
toms are prominent; of the sensory symptoms, numbness of the 
affected parts, with rheumatic stiffness and lameness, and tear- 
ing, drawing pains, are the most conspicuous.— Phosphorus. 
Burning, stinging pains; sensation of numbness in the parts; 
feeling of constriction in the extremities; girdle-sensation. Spi- 
nal caries. Great exhaustion. According to O'Conner, in as- 
cending sensory and motor paralysis, beginning at the ends of 
the fingers and toes.— Plumbum. Fulgurating, lightning-like 
pains. Great atrophy of the paralyzed parts. — Arnica. Neuri- 
tis from a bruise or a wound. Sore, bruised pain. — Hypericum. 
Neuritis from a lacerated wound or from penetrating wounds 
made by some pointed instrument. Excessive pain, fullness 
and soreness of the affected parts; worse from damp weather. 
"Implication of posterior nerve-roots" (O'Conner). 

Consult also: Nux vomica (alcoholic form; loss of power in 
the legs; numbness, formication); Gelsemtum (paralysis of 
lower extremities; legs feel like lead); Causticum (paralysis); 
Argentum nitricum (ataxic symptoms); Cimicifuga (O'Con- 
ner's best remedy in alcoholic neuritis); Mercury (dropsical 
swelling; syphilitic cases); Pulsatilla, and others. 

O'Conner reports a cure of post-diphtheritic polyneuritis 
cured by Diphtheria-toxine (200th). He recommends Ber- 
beris when the neuritis is in the distribution of the nerves from 
the lumbar and sacral plexus, with characteristic bladder- 
symptoms; ^Esculus hippocastanum when in the lesser 
sciatic and with characteristic rectal symptoms; Paraira 
brava when in the anterior crural, with characteristic bladder 
symptoms; Anantherum when in the upper dorsal roots. 

NEUROMA. 

Neuromata or new growths in the peripheral nerves may oc- 
cur at any age and in any locality. Two kinds are recognized: 
the true and the false. The former contain nerve-cells or nerve- 
fibres; the latter are connective-tissue formations (fibroma, 
myxoma, sarcoma, lipoma). 

The most common is the amputation neuroma, a little oval 
tumor of the size of a pea, or larger, found in the cut end of a 
nerve in a stump after amputation. It is exceedingly painful 



DISEASES OF THE NERVES. 619 

and may recur after extirpation. Its presence frequently causes 
violent muscular twitchings. The so-called tubercula dolo- 
rosa consist of little nodules found on the nerves of the skin, 
about the joints, face, scrotum, back, neck, and elsewhere, con- 
stituting true or false neuromata which are usually movable 
and exceedingly sensitive to pressure. They cause much an- 
noyance because they are easily knocked. At irregular times 
they appear only slightly or not at all painful, and then they 
diminish somewhat in size; occasionally they disappear spon- 
taneously. Neuromata occur also on the nerves of the cauda 
equina and on peripheral nerve-trunks where they can be easily 
detected. Plexiform neuromata is a congenital affection, the 
nerve-tumors appearing in large numbers, by hundreds, in 
various parts of the body. 

The symptoms consist of pain, often of a neuralgic charac- 
ter; occasionally, as in the cauda equina, they may by pressure 
cause anaesthesia and motor paralysis, oftener tremors or tonic 
spasms. In many cases they are painless. 

The treatment consists of excision. If the latter be not prac- 
ticable, electricity may be tried. 

DISEASES OF THE CRANIAL NERVES. 

DISEASES OF THE OLFACTORY NERVE. 

The olfactory centre may be affected by destructive or irrita- 
tive lesions. The former results in loss of smell (anosmia); the 
latter, in hallucinations of smell. 

Anosmia. — Central anosmia may occur in such cerebral- dis- 
eases as give rise to hemiplegia and aphasia, the loss of smell 
showing itself in the nostril on the same side as the lesion. It 
may also result from tumors of the anterior fossa of the skull, 
exostoses, or meningitis at the base of the frontal lobe. Total 
loss of smell may be due to atrophy of the nerve in old people 
(senile anosmia) and is occasionally seen in hysteria. 

Partial anosmia is usually due to peripheral causes, as: nasal 
catarrh ; great dryness of the nasal cavity ; the result of certain 
occupations in the pursuit of which workmen cease to notice 
odors which at first were very offensive (scavengers, workmen 
in glue-factories, etc.); the chemical action of certain substances 
which are continuously inhaled (chlorinated lime). 



620 DISEASES OF THE NERVOUS SYSTEM. 

Hallucinations of smell {Parosmia) occur in pS}'choses, mi- 
graine, tic douloureux, epilepsy (aura), tabes, hysteria. Some- 
times parosmia occurs as an anomaly in perfectly well per- 
sons. A former patient of mine found the odor of the wood- 
violet unbearably offensive, and would faint if obliged to inhale 
it. The hallucinations are almost universal^ of a disagreeable 
character. 

Hyperosmia or increased sensitiveness of smell is found in 
hysteria and insanit}\ 

Treatment. — This in all cases must be directed to the primary 
cause. If due to peripheral causes, the application of the fara- 
dic or galvanic current to the nasal cavity may prove helpful. 
If not of central origin, recovery may take place spontaneously. 
In testing the sense of smell, the tests must be applied to one 
nostril at a time. Substances which may irritate the trigemi- 
nus (smelling-salts, snuff, etc.) must be avoided; the essential 
oils are free from this objection. A rhinoscopic examination 
should always be made. 



DISEASES OF THE OPTIC NERVE. 

LESIONS OF THE RETINA. 

Changes in the retina are especially important in albumi- 
nuria, leukaemia, anaemia and syphilis. Haemorrhages indicate 
retinitis ; they are at first bright-red, then black ; they follow 
the course of the vessel or are seen in the layers of the nerve 
fibres. Opacities are the result of inflammatory exudation, 
fatt\ r degeneration, or sclerotic changes. There is frequently 
cloudiness or turbidity from the effusion of serum in the layers 
of the retina. Atrophy of pigment or tubercular, and other, 
new formations give rise to white spots on the choroid. The 
retinal changes occurring in the course of albuminuria {albumi- 
nuric retinitis) are important. Disturbance of vision is one of 
the earliest sjmiptoms. Gowers recognizes an inflammatory 
and a degenerative form. In the former the retina is greatly 
swollen, the arteries are obscured, and haemorrhages are numer- 
ous. In the degenerative form there are small white spots 
chiefly about the macula, linear and flame-shaped haemor- 
rhages, and sometimes diffuse opacity. Occasionally the optic 



DISEASES OF THE NERVES. 621 

nerve chiefly is involved, while the retina may almost escape or, 
again, present all the signs of severe inflammation. In diabetes 
the changes are similar. In profound anaemia retinal haemor- 
rhages are common, a neuro-retinitis less frequent. Leukemic 
retinitis is characterized by the presence of yellowish-white 
spots which are almost pathognomonic; there is also turbidity 
and haemorrhage. Haemorrhages occur in purpura, scurvy and 
chronic lead-poisoning. 

Functional Disturbances of the Retina are chiefly of toxic 
origin. Here belong the sudden and transient blindness of 
uraemia or of lead-poisoning, and the cases in which amaurosis, 
often persisting for months, follows toxic doses of quinine; 
also the amaurosis of tobacco-poisoning, the latter amounting 
to dimness of sight rather than blindness. Hysterical amauro- 
sis, night-blindness (nyctalopia) and hemeralopia (dimness of 
vision with bright light, natural or artificial) and retinal hy- 
peraesthesia come under this heading. 

LESIONS OF THE OPTIC NERVE. 

Papillitis, sometimes called Optic Neuritis or Choked Disk. 
Yon Graefe considered it the result of venous engorgement 
caused by mechanical obstruction to the return flow of venous 
blood; more recent observers attribute its occurrence to com- 
pression of the optic nerve in its passage through the lamina 
cribrosa of the sclerotic; Stephen Mackenzie points out that its 
appearance as an occasionally unilateral affection on the side 
opposite to the seat of the brain tumor with which it is associ- 
ated tends to show that it is the outcome of a descending neu- 
ritis following the course of the nerve-fibres. The pathological 
changes in the disk consist of blurring, with increase of the 
rosy tint of the surface. There is then swelling, opacity, loss 
of natural form of the disk, striation, haemorrhage. The veins 
are enlarged and gorged with blood; the arteries are narrow. 
There may be retinitis (neuro-retinitis). Unless recovery grad- 
ually takes place, as is the rule in the mild form, there is great 
swelling and exudation, so the disk appears very prominent, 
with striations, haemorrhages, and patches of inflammatory 
exudation , eventually resulting in atrophy. 

Papillitis occurs chiefly in connection with intracranial 



622 DISEASES OF THE NERVOUS SYSTEM. 

tumor, regardless of location or character. In the course of 
tumor, temporary increase of its size, with consequent increased 
compression of vessels or brain substance, may occasion sud- 
den spells of blindness which pass away after some hours or 
da3 r s, described by H. Jackson as "epileptiform amaurosis." 
Papillo-retinitis may occur in tubercular meningitis, more 
rarely in cerebro-spinal meningitis; it is a feature of chronic 
brain-disease of childhood. The remedies most likely to be use- 
ful are : Belladonna, Phosphorus, Nux, Pulsatilla. 

Atrophy of the Optic Nerve may, as a primary atrophy, be 
idiopathic or occur in spinal disease (especially locomotor 
ataxia, lateral sclerosis, paralysis of the insane). Occasionally 
it is due to syphilis, alcohol, lead-poisoning, excessive use of to- 
bacco, sexual excesses, etc. As a secondary affection it follows 
papillitis (consecutive atrophy). Loss of sight varies from 
slight disturbances to blindness. The perception of colors is in 
many cases altered. In the main, the prognosis is bad. 



LESIONS OF THE CHIASM AND TRACT. 

The characteristic expression of these lesions is hemianopsia, 
(or hemianopia) or loss of vision in one-half of the visual field 
in one or both eyes. Many forms are recognized, according 
to the peculiar distribution of the blindness in individual cases. 
Thus, lateral hemianopsia means blindness in the nasal half- 
field of one eye and the temporal half-field of the other; tem- 
poral hemianopsia, loss of vision in the temporal halves of the 
visual field; nasal hemianopsia, destruction of the nasal half-field 
of vision, etc., etc. The explanation of the special phenomena in 
each form are found in the arrangement of the visual tract in 
the brain, in the partial decussation of the optic nerves at the 
chiasm and commissure, and the relation of certain nerve fibres 
to the retina. Theoretically hemianopsia is of particular interest 
because it affords a pointed application of the principles of 
cerebral localization. The tests necessary to determine the ex- 
act seat of the lesion are not easy, and should be made by spe- 
cialists. The phenomen may occur as a functional disturbance 
in migraine and hysteria, but in the permanent form must be 
considered a sj^mptom of structural changes in the visual tract. 



DISEASES OF THE NERVES. 623 



AFFECTIONS OF THE MOTOR NERVES OF THE 
EYE. 

THIRD NERVE. 

The third nerve by its superior branch supplies the levator 
palpebral superioris and the superior rectus; by its inferior 
branch, the internal and inferior recti and the inferior oblique 
muscles. It also supplies the ciliary muscles and the con- 
strictor of the iris. Affections of the nerve may be of the centre 
or of its course, and may express themselves in paralysis or 
spasm . 

Paralysis. — Nuclear lesion of the third nerve may cause gen- 
eral ophthalmoplegia; if that portion of the nucleus only is in- 
volved which presides over the iris, there will be loss of reflex 
(Argyll-Robertson pupil). Involvement of the nerve-trunk (by 
compression, as from exudation, aneurism or gummata, or by 
inflammation, as in diphtheria) is followed by symptoms of 
which external strabismus, double-vision and ptosis are the 
most important. If the affection of the nerve be partial, the 
paralysis will be correspondingly limited; thus, involvement of 
the ciliary branch alone is followed by paralysis of the iris and 
loss of power of accommodation. Exceptionally, recurring 
paralysis of this nerve has been observed, usually in women of 
a neuropathic disposition; such attacks rarely last more than 
a few days, and recur at varying intervals. 

Ptosis may be a congenital defect, with a hereditary predis- 
position to it; occasionally it is seen, in a transient form, in del- 
icate and neurotic women, frequently occurring in the early 
morning. It may arise from lesion of the third nerve at its nu- 
cleus or along its course, often associated with paralysis of all 
the muscles controlled by the third nerve; or it may occur 
alone, evidently the result of cerebral lesion not yet localized; 
or it is observed in connection with paralysis of the cervical 
sympathetic, with vaso-motor disturbances; or it may consti- 
tute a feature of the f acio-scapulo-humeral type of muscular 
atrophy, in which case the ptosis is bilateral. 

Paralysis of the ciliary muscle (cycloplegia) may occur in 
one or both eyes. It is usually of nuclear origin and is seen in 
diphtheria and locomotor ataxia. The paralysis results in loss 



624 DISEASES OF THE NERVOUS SYSTEM. 

of power of accommodation, especially affecting near sight. 
In diphtheritic paralysis it occurs often and early. 

Paralysis of the iris (iridoplegia) may affect the power of 
accommodation (accommodative iridoplegia), the pupil not 
contracting when focusing the eye upon near or distinct objects 
in the same line; or it may assume the form of a reflex iridople- 
gia in which the pupil does not contract to bright artificial 
light. Retention of power of accommodation with the loss of 
iris reflex to light constitutes the Argyll-Robertson pupil. Irido- 
plegia is commonly associated with smallness of the pupils. 
Erb has pointed out that the skin-reflex (dilatation of the pupil 
from irritation of the skin, especially on the neck) is usually 
lost with the reflex contraction. 

Anisocoria or inequality of the pupils is seen in general par- 
alysis of the insane and locomotor ataxia; it may occur in per- 
sons in good health. 

FOURTH NERVE. 

Nuclear paralysis of this nerve may be a feature of involve- 
ment of oculo-motor centres. Compression of the nerve (aneu- 
rism, tumor, inflammatory exudate) causes paralysis of the 
superior oblique, with defective downward and inward move- 
ment of the eye-ball and double-vision upon looking down- 
ward. 

SIXTH NERVE. 

This nerve supplies the external rectus; paralysis of the nerve 
(from tumors, meningeal lesions, cold) results in internal stra- 
bismus with double vision on looking towards the paralyzed 
side. Involvement of the nucleus causes, in addition to the par- 
alysis of the external rectus, inability of the internal rectus of 
the opposite side to turn that eye inward. "As a consequence 
of this, the axes of the eyes are kept parallel, and both are con- 
jugated deviated to the opposite side, away from the side of 
the lesion. The reason of this is that the nucleus of the sixth 
nerve sends fibres up in the pons to that part of the nucleus of 
the opposite third nerve which supplies the internal rectus: we 
have thus paralysis of the internal rectus without the nucleus 
of the third nerve being involved, owing to its receiving its 



DISEASES OF THE NERVES. 625 

nervous impulses for movement from the sixth nucleus of the 
opposite side. As the sixth nucleus is in such close proximity 
to the facial nerve in the substance of the pons, it is frequently 
found that the whole of the face on the same side is paralyzed, 
and gives the electrical reaction of degeneration, so that with 
a lesion of the left sixth nucleus there is conjugate deviation of 
both eyes to the right, i. e., paralysis of the left external and 
the right internal rectus, and sometimes complete paralysis of 
the left side of the face." (Bevoor.) 



OPHTHAI.MOPI.EGIA. 

An ocular palsy of nuclear origin (degenerative changes) giv- 
ing rise to gradual, sometimes rapidly progressing, paralysis of 
all the ocular muscles or of the external or internal groups 
alone. It occurs nearly always in association with bulbar par- 
alysis, locomotor ataxia, general paralysis, or progressive 
muscular atrophy; some authors connect it with syphilitic dis- 
ease. 

In the external form (0. externa) the paralysis begins in the 
levators of the eye-lids, extending to other muscles so that the 
eye eventually becomes fixed and objects out of a straight line 
can only be seen by turning the head. Ptosis is common; there 
may be slight protrusion of the eye-ball. The internal form in- 
volves the ciliary muscle and the iris; it rarely occurs alone. 
According to O'Conner, the favorite remedies at the New York 
Ophthalmic Hospital, for paralysis of the muscles of the eye- 
ball, are Agaricus, Gelsemium and Physostigma, with Caus- 
ticum and Conium in isolated ptosis and in ciliary muscle par- 
alysis. 

Acute ophthalmoplegia {polioencephalitis superior acuta) is 
sudden in onset and rapid in development. Headache, vertigo, 
vomiting, delirium or somnolence are swiftly f ollowed by par- 
alysis of the muscles of the eye. There is usually rapid pulse, 
normal temperature, sometimes ataxic gait, optic neuritis, with 
death in one or two weeks. Cases have occurred in chronic al- 
coholism, after infectious disease (influenza), from poisoning 
by spoiled sausage, carbon monoxide, and nicotine. 
40 



626 DISEASES OF THE NERVOUS SYSTEM. 



SPASM OF THE OCULAR MUSCLES. 

Nystagmus consists of bilateral and, usually, horizontal 
rlrythmical movements; in the unilateral form the movements 
are more liable to be vertical. The pathology of the affection 
is in doubt. It occurs in cerebral affections associated with 
blindness, and in sclerotic and chronic cerebro-spinal lesions, in 
albinism, miners, and sometimes in affections of the sympa- 
thetic nervous S3^stem. 

Convulsions of the eye may be hysterical; in such cases the 
eyes are usually strongly drawn up. Tonic, more rarely clonic, 
spasm may occur in basilar brain disease. 

Occasionally spasm of the levator palpebral is seen; also 
rhythmical contraction and dilatation of the iris (hippus). 

Conjugate deviation of the eyes (and head) consists of a 
movement of the eyes to one side by spasm of the external rec- 
tus of one e3^e and the internal rectus of the other, and of the 
sterno-mastoid muscle on the side opposite to the direction of 
the movement. It occurs in cerebral lesions, especially early in 
hemiplegia. 

LESIONS OE THE FIFTH NERVE. 

Paralysis may occur from haemorrhage in organic disease of 
the pons, injury at the base of the brain (meningitis, caries, 
rarely fracture) or compression of any of its branches by tu- 
mors or aneurism. 

Symptoms.— There is anaesthesia in the parts supplied by the 
nerve, i. e., one-half of the face and head, preceded by numb- 
ne'ss and tingling, with loss of smell and taste (in the anterior 
two-thirds of the tongue; not a constant symptom). Diminu- 
tion of the lachrymal, salivary and buccal secretions; swelling 
of the gums on the affected side; looseness of the teeth; herpetic 
eruptions, especially in the region supplied by the upper branch, 
often accompanied with severe pain. Inflammation of the eye, 
with opacity of the cornea and, finally, corneal ulceration. 
The motor symptoms consist of loss of power in the muscles of 
mastication on the affected side. 

Spasm of the Muscles of Mastication. — Trismus may occur as 
an independent affection, but usually is associated with gen- 



DISEASES OF THE NERVES. 627 

eral convulsions. When the spasm is tonic, there is complete 
closure of the jaws, so are they opened only by force and at times 
with extreme difficulty (Lock-jaw). This symptom is seen in 
tetanus, rarely in tetany or hysteria. It may arise from expo- 
sure to cold, caries of the jaw or teeth, or from central cause. 
Clonic spasm of the jaw consists of a single, forcible contrac- 
tion (in chorea) or of rapidly repeated contractions, like chat- 
tering of the teeth. 

Neuralgia of the trigeminus is discussed elsewhere (see "Neu- 
ralgia"). 

LESIONS OF THE FACIAL NERVE. 

Paralysis of the seventh nerve (Bell's Palsy) may result 
from lesions in the cortex (supranuclear paralysis), from le- 
sions of the nucleus itself (nuclear paralysis), or from involve- 
ment of the nerve-trunk (infranuclear paralysis). 

Supranuclear paralysis is the result of organic disease (tu- 
mors, abscess, chronic inflammation, degeneration) in the re- 
gion of the internal capsule, and is nearly always associated 
with hemiplegia, the paralysis of the face and the hemiplegia 
occurring on the same side. The peculiarities of this form are: 
persistence of normal electrical excitability of nerves and mus- 
cles and escape of the orbicularis palpebrarum and frontalis 
muscle. Nuclear paralysis is due to tumors, softening or haem- 
orrhage involving the nerve-centre; it sometimes occurs in diph- 
theria and in anterior polio-myelitis. Infranuclear paralysis 
may be due to exposure to cold (neuritis within the Fallopian 
canal), syphilis (early in second stage), disease of the ear 
(otitis media, with caries), blows and injuries to the nerve at its 
point of emergence from the styloid foramen. Should the in- 
volvement of the nerve occur before it makes its exit from 
the pons, the lesion being in the lower section of the pons, 
cross-paralysis occurs; i. e., the face is involved on the same 
side as the lesion, while the hemiplegia is on the side opposite 
to the lesion; per contra, the lesion being in the upper division, 
the paralysis of both face and limbs is on the side opposite to 
the lesion, and only the lower fibres of the facial nerve are in- 
volved. 

Symptoms. — The paralysis usually begins suddenly; when 



628 DISEASES OF THE NERVOUS SYSTEM. 

there are prodromata, they consist of abnormal sensations of 
taste, slight ringing in the ears, and vague pains about the face 
and ear. 

The paralysis involves the entire half of the face, save in the 
supranuclear form, as already stated. The affected side of the 
face is relaxed, utterly motionless, void of expression, without 
a wrinkle. The eye cannot be closed; when the attempt to do 
so is made, the upper lid sinks down from its weight, and the 
eye is turned upward, covering the pupil, but leaving a large 
space between the e3 r e-lids (lagophthalmus); the eyes "water" 
freely, and conjunctivitis and more serious inflammatory 
troubles of the eye result from exposure to dust and other irri- 
tating substances. The corner of the mouth on the affected 
side droops; the upper teeth cannot be shown, because the 
angle of the mouth cannot be raised; it is impossible to smile 
or to laugh; when attempting to drink, fluid escapes from the 
mouth because it cannot be perfectly closed; he cannot whistle 
or form labial sounds in speaking; when eating, the food col- 
lects on the affected side. The tongue, when protruded, ap- 
pears to be drawn toward the affected side; in reality it is in 
the median line. Taste is not affected when the involvement of 
the nerve is outside the skull. Disturbances of hearing are fre- 
quent, but are often due to previously existing disease of the 
ear. In some cases there is sensitiveness to loud sounds and to 
low notes, which is attributed to paralysis of the stapedius 
muscle. Reflex movements and the power to wink or to 
wrinkle the forehead are lost. The face may be swollen on the 
affected side and there may be herpetic eruptions. Pain is not 
common. 

The duration is variable. 

The prognosis is good in cases due to cold and syphilis. Re- 
covery may occur when the paralysis results from injury; the 
case is less hopeful when there is disease of the middle ear; it is 
practically hopeless in the presence of serious organic lesions. 
Erb considers the prognosis good, and recovery in from fifteen 
to twenty days assured, when the electrical reactions are nor- 
mal. When there is only lessening of the electrical excitability 
of the nerve, and that of the muscle is increased to the galvanic 
current, and the contraction sluggish, recovery will probably 
take place in four to six weeks or maybe delayed for from eight 



DISEASES OF THE NERVES. 629 

to ten weeks. When there is reaction of degeneration and the 
mechanical excitability is altered, the prognosis is relatively 
unfavorable, and recovery may not take place for from two to 
eight months, or even for twelve or fifteen months. 

Treatment. — The application of cotton-wool to the face 
serves to retain heat, and, if employed early, may accomplish 
much good. Both blistering and the thermo-cautery are ad- 
vised; of the two, the latter is to be preferred. Pains should 
be taken to protect the eye by closing it, using strips of adhe- 
sive plaster or a bandage. If the eye is allowed to be kept open 
during the day, in the house, a bandage should be used during 
sleep. The remedies which are oftenest useful are Rhus toxi- 
codendron (rheumatic tendency, from exposure to wet), 
Aconite (in recent cases, from exposure to cold), Causticum 
(right side; twitchings of affected muscles), Gelsemium (diph- 
theria, pain in the face, twitching of muscles), Silica, Hepar 
sulphur and Aurum in connection with middle-ear disease, 
Belladonna, Ruta, Hypericum (traumatism), Kali hydriod- 
icum (syphilis), Arsenicum, Iodum. 

In due time massage and electricity may be used. A mild gal- 
vanic current (positive pole behind the ear, negative pole over 
the muscles) should be used daily, each sitting not to exceed fif- 
teen minutes. 

Spasm. — Excluding the habit spasm of children, elsewhere 
considered, the form here discussed is the simple facial spasm 
occurring as,a primary affection or following paralysis. The 
disease usually occurs in adults. It sometimes depends upon a 
brain-lesion, frequently cortical; sometimes it is the result of 
pressure at the base of the brain from tumor or aneurism. The 
spasm usually first attacks the orbicularis palpebrarum and 
the zygomatics, causing rapid contraction of the muscles about 
the eye (blepharospasm), sometimes tonic contraction. When 
the lateral facial muscles are involved, there is twitching of the 
side of the face with incomplete closure of the eye. Sometimes 
the muscles of the lower face suffer severely, especially the de- 
pressors of the angle of the mouth. A number of these spasms 
occur with lightning-like rapidity, after which there is a rest, 
soon to be broken by a renewal of the spasms. The affection 
may be unilateral or bilateral; it is aggravated by great ex- 
haustion, involuntary movements of the face, and emotional 



630 DISEASES OF THE NERVOUS SYSTEM. 

excitement. There is rarely much pain, but tender points have 
been observed, especially in the supraorbital branch of the fifth 
nerve. The prognosis is doubtful so far as a cure is concerned. 
Treatment includes a thorough search for the primary cause 
and attempts at its removal. All kinds of treatment have been 
employed, without even reasonable success. Weir-Mitchell re- 
ports one cure by the daily use of the rhigolene spray. Gal- 
vanism is praised, but, so far as my knowledge extends, no 
cures are reported. Surgery has accomplished nothing. I have 
seen good results follow the use of Ignatia lx in the case of a 
man who had for some years suffered from ataxic symptoms. 

AUDITORY NERVE. 

Affections of the auditory nerve are rarely of cortical origin. 
It is known that destruction of the first temporal gyrus 
causes word-deafness. Degenerative changes of the nerve fibre 
after it has left the cortical centre, whether originally from tu- 
mor, inflammatory affections, haemorrhage or other causes, 
may result in deafness. A primary degeneration of the nerve 
may occur in locomotor ataxia, and serious involvement of it is 
common in cerebro-spinal meningitis. The general practitioner 
deals almost exclusively with disturbances of hearing which re- 
sult from lesion in the labyrinth, in the greater number of cases 
due to disease of the middle ear. 

Increased function (hyperesthesia and irritation) may as- 
sume the form of hyper-acusis or abnormal sensitiveness to 
sound, as seen in hysteria and brain-disease, and as is illus- 
trated in the special sensitiveness to low notes arising from 
paralysis of the stapedius. The term dysacusis is used to cover 
that abnormal sensitiveness to all sounds which is common in 
conditions of weakness with nervous irritability, as seen in ner- 
vous headaches. Irritation may also give rise to whistling, 
whirring, ringing, roaring noises in the ear; this subjective sen- 
sation is called tinnitus aurium. It may be caused by circula- 
tory disturbances, disease of the middle ear, or wax on the 
drum, and may be artificially produced by sudden stimulation 
of the nerve. It is sometimes a constant symptom and the 
cause of great distress, as in the insane. It is often present in 
migraine, and may constitute an epileptic aura. A continuous 



DISEASES OF THE NERVES. 631 

murmur or bruit may be present in anaemic and neurasthenic 
states. 

Diminished function causes partial or complete deafness, 
which must not be mistaken for the deafness arising from such 
disease of the middle or even external ear as prevents the con- 
duction of sound to the cochlea. The differentiation between 
these two forms of deafness (i. e., deafness from disease of the 
ear and nerve-deafness) depends upon tests made with the 
tuning-fork. If bone-conduction is materially lessened or lost, 
the auditory nerve or its endings is at fault; if the sound be- 
comes distinctly audible when the tuning fork is applied to the 
mastoid bone, when it could not be heard at the outer ear> 
there is disease of the middle or outer ear. 

Auditory vertigo is common with diseases of the ear. The 
term Meniere's Disease, at one time restricted to special forms 
of auditory vertigo, is now applied to all cases of sudden ver- 
tigo, accompanied with noises in the ears and deafness. 

Symptoms. — The onset is sudden. There is all at once a 
sense of extreme fulness in the ear, accompanied by loud noises, 
often shrill and whistling, with a sensation as if one were turn- 
ing rapidly and would fall, or as if objects about him were 
turning, or both. The attack may be initiated with a sensa- 
tion as though he had received a violent blow behind the ear, 
and he may actually fall to the ground. There may be mental 
confusion or momentary loss of consciousness. Pallor of the 
face, sense of extreme weakness, with nausea, vomiting, and 
profuse clammy sweating of the forehead and face follow 
quickly. The attack is accompanied with more or less deafness 
of nervous origin and, occasionally, convulsive movements of 
the eye-ball (nystagmus). The paroxysms recur at varying in- 
tervals; there may be several in a day or they may be weeks or 
months apart. They may grow in severity as the case becomes 
fully established; in bad cases the vertigo may become almost 
constant. Usually the vertigo ceases after the labyrinthine 
nerve organs have been destroyed, a condition which necessa- 
rily results in complete deafness. The affection is rare in youth, 
and is oftenest seen in men who have passed their fortieth year. 

The cause of aural vertigo is still in doubt. By some it is con- 
sidered an affection of the labyrinth, giving rise to disturbances 
of the equilibrium; others think it is due to an involvement of 



632 DISEASES OF THE NERVOUS SYSTEM. 

the centres which preside over hearing and equilibration; still 
others believe that the real cause lies in disturbed vaso-motor in- 
fluences, causing variations in the intra-labyrinthine pressure. 

The diagnosis of aural vertigo rests upon the presence of 
noises in the ear and other evidence of the disturbance of the 
auditory nerve at the commencement of the attack. Differen- 
tiation from epilepsy may be difficult, especially when the epi- 
leptic seizure is preceded by an aura which presents tinnitus, 
vertigo, and nausea. 

Treatment.— Glonoine when the "sense of fulness" in the 
ear and head is marked, with throbbing, roaring, shrieking 
noise in the ear.— Chininum sulphuricum. The noise in the 
ears excludes every other sound. In anaemic, debilitated per- 
sons.— Aurum. Tension in the ears, with tinnitus and deaf- 
ness ; in the eyes, with dimness of sight. Nervous palpitation. 
Staggers as though drunk, with tendency to fall toward the 
left side.— Salicylic acid. Tendency to fall to the left; sur- 
rounding objects move toward the right.— Petroleum. Ver- 
tigo felt chiefly in the occiput, with great nausea; deafness; 
sensation as if the ears were filled with water.— Causticum. 
Ringing in the ears; sense of weakness and anxiety; everything 
turns in a circle; cracking and snapping sounds in the ear when 
he turns the head; reverberation of sounds in the ear, even of 
his own voice. Tendency to excessive accumulation of wax in 
the ear.— Ledum. Ringing noise in the ear; roaring sound, as 
of wind, in the ear; cannot hear well; feels as though there 
were cotton in the ear. Vertigo, with tendency to fall for- 
ward. — Tabacum. Vertigo, with nervous deafness, great 
weakness, sense of oppression and anxiety, dilated pupils, pale 
face covered with profuse cold sweat, and deathly nausea. — 
Gelsemdjm, Causticum, Duboisia, Arnica, Ferrum and Kali 
bromatum should also be consulted. 



GLOSSO-PHARYNGEAL NERVE. 

Verj^ little is known of the functions of this nerve. They are 
probably of a mixed character; affections of this nerve, alone, 
are scarcely demonstrable. It was thought that disturbances 
of taste result from loss of function of the gloss o-pharyngeal, 



DISEASES OF THE NERVES. 633 

but Gowers positively denies this, attributing this symptom to 
disease of the root of the fifth nerve. 

Ageusia or loss of the sense of taste may result from disturb- 
ance in the peripheral end organs, in the mucous membrane of 
the tongue, as seen in fevers ("dry" tongue) and dyspepsia 
("furred" tongue); from the action of local irritants (pepper, 
mustard, vinegar, etc.); and from involvement of the root of the 
fifth nerve. 

Parageusis or perversion of the sense of taste is rare, save in 
hysterics and the insane. Hallucinations of the sense of taste 
are observed in insanity and in the aura of epilepsy. 

PNEUMOGASTRIC NERVE. 

Pharyngeal Branches. — The pharyngeal plexus of nerves is 
formed by branches of the pneumogastric and glosso-pharyn- 
geal. Paralysis of the parts supplied results from involvement 
in the nuclei (bulbar paralysis) or of the nerves (neuritis). It 
gives rise to difficulty of swallowing (dysphagia); particles of 
food often enter the larynx or nares. The paralysis may be 
unilateral or bilateral; if the former, the effects are compara- 
tively trifling. Functional irritation of the nerves causes 
spasms of the pharynx, as observed in hysteria and hydropho- 
bia. 

Laryngeal Branches. — Paralysis affects the abductors or the 
adductors; the former may be bilateral or unilateral. 

Bilateral paralysis of the abductors results from cold or 
laryngeal catarrh; it is seen in hysteria and as a central affec- 
tion in tabes and bulbar paralysis. The cords are in close ap- 
position, and their failure to separate during inspiration is re- 
sponsible for the whistling, noisy stridor which accompanies 
the effort. The condition is dangerous, since a very slight de- 
gree of additional swelling of the parts would cause asphyxia. 
The voice is not affected. Unilateral abductor paralysis is due 
to involvement of one recurrent nerve (tumor, aneurism, etc.). 
The cord on the affected side does not move during inspiration. 
In total bilateral or unilateral palsy the cords on one or both 
sides are moderately abducted and perfectly motionless. The 
power to cough is lost; there is aphonia and stridor on deep in- 
spiration in the bilateral form, and hoarseness of voice with 



634 DISEASES OF THE NERVOUS SYSTEM. 

slight stridor on deep breathing in total unilateral palsy. 
Neither voice nor inspiration are materially changed or embar- 
rassed. 

Adductor paralysis is characterized by inability to bring the 
cords together on attempts at phonation, though their position 
is normal and the} 7 move in respiration; hence, the striking 
symptom produced is loss of voice (aphonia). It is seen in se- 
vere la^ngeal catarrh, after excessive use of the voice, and in 
hysteria. 

Spasm of the muscles of the larynx is seen in laryngismus 
stridulus and in the laryngeal crises of locomotor ataxia. The 
term spastic aphonia refers to the occurrence of a la^ngeal 
spasm when an attempt is made to speak, preventing phona- 
tion. 

Sensory disturbances of the larynx are rare. Anaesthesia 
occurs in diphtheritic neuritis and bulbar paralysis, sometimes 
in hysteria. The condition is one of considerable danger, as it 
ma}' give rise to the entrance of particles of food into the 
trachea. 

Cardiac Branches. — Inhibition and control of the action of 
the heart is carried on by fibres which pass in these branches. 
Irritation of these fibres slows the action of the heart. Com- 
plete paralysis, on the other hand, abolishes the inhibitory in- 
fluence and is followed by excessivery rapid action of the heart. 

Disturbances of sensation are described elsewhere. (See "Neu- 
rosis" of the heart). 

Pulmonary Branches— Little is known concerning their func- 
tion ; asthma is considered a neurosis of these fibres. 

Gastric and (Esophageal Branches.— These furnish a large 
portion of the motor supply to the stomach and are concerned 
in the act of vomiting, as a reflex action or as the result of di- 
rect irritation (meningitis). Irritation of the sensory fibres 
causes gastralgia; all the gastric neuroses are closely associated 
with pneumogastric disturbances. The gastric crises of loco- 
motor ataxia are the result of central irritation of the nuclei. It 
is thought that the sensation of hunger is caused by the pneu- 
mogastric. (Esophageal spasm may be a reflex phenomen, may 
be very painful, and resemble stricture; it occurs not infre- 
quently as a manifestation of hysteria. 



DISEASES OF THE NERVES. 635 

SPINAL ACCESSORY NERVE. 

Paralysis —It must be borne in mind that the internal, 
smaller part of the spinal accessory joins the pneumogastric 
and helps supply the larnygeal muscles; paralysis of this branch 
is discussed with the affections of the laryngeal branches of the 
pneumogastric. Disease or compression of the external por- 
tion causes paralysis of the sterno-mastoid and of the 
trapezius on the same side. Paralysis of the sterno-mastoid 
gives rise to difficulty of rotating the head to the opposite side, 
but not to true torticollis. Paralysis of the trapezius is not 
complete, for it is in part supplied from the cervical nerves. 
This partial paralysis is recognized by a change in the contour 
of the outer side of the neck, which from a nearly straight line 
changes to a concave curve, which becomes very apparent when 
the patient draws a deep breath. The loss of power in the 
middle portion of the trapezius causes slight drooping of the 
shoulder, rotation inward of the angle of the scapula, and im- 
pairment of the power to raise the arm. When there is bi- 
lateral paralysis of the sterno-mastoids, the head has a ten- 
dency to fall backward; when of the trapezius, it falls forward. 
These bilateral forms may occur in progressive muscular 
atrophy. 

Accessory Spasm {Torticollis; Wry Neck). — Wry neck is 
caused chiefly, but not exclusively, by spasm of cervical muscles 
which are supplied by the accessory nerve. 

Congenital (or fixed) wry neck occurs in children, usually 
affects the right side, and often is not noticed until the child is 
several years old. It depends upon shortening of the sterno- 
mastoid, which feels hard and firm. The affection is associated 
with a strong tendency to facial asymmetry. Its causation is 
in doubt; it had been considered the result of intra-uterine in- 
jury of the affected muscles or of violence done during parturi- 
tion; Golding-Bird claims that both torticollis and the facial 
asymmetry are of central origin. The treatment is simple and 
effective; it consists of tenotomy; unfortunately the facial 
asymmetry is more readily noticed after, than before, the oper- 
ation. Spasmodic wry neck is tonic or clonic, exceptionally 
both. It occurs in adults, in men oftener than in women. In 
the tonic form, when the sterno-mastoid is at fault, the occiput 



636 DISEASES OF THE NERVOUS SYSTEM. 

is drawn toward the shoulder of the affected side, elevating the 
chin and rotating the face upward and toward the other 
shoulder. When the trapezius also is involved, the occiput is 
still more strongly drawn toward the affected side. The af- 
fected muscles are rigid, and in prolonged cases there may be 
spinal curvature, with the convexity toward the sound side. 
In the clonic form several muscles ma}- be involved, the sterno- 
mastoid nearly always. The head usually is drawn somewhat 
backward; the head may be rotated so that the mastoid ap- 
proaches the inner end of the clavicle, raising the chin and turn- 
ing the face to the opposite side. The trapezius, splenius cap- 
itis, plat\ r sma myoides, and ether muscles, may be involved. 
In the rare cases of bilateral spasm a strong backward move- 
ment results which may make the face assume a horizontal po- 
sition, looking upward. The contractions may occur suddenly 
or there may first be some stiffness and pain in the neck; they 
recur at very brief intervals and usually are accompanied with 
pain and sense of great muscular fatigue. They cease during 
sleep. There may develop in time hypertrophy of the affected 
muscles. Neither causation nor pathology are understood. 
The neuropathic tendency seems clearly pronounced in some 
cases; violent emotions, excitement and fatigue exaggerate the 
difficult}^. The course is tedious and the prognosis not encour- 
aging; occasionally recovery takes place, but often improve- 
ment is merely temporary. 

Treatment.— Mechanical devices are of slight benefit and sur- 
gical methods so far proposed have accomplished nothing. 
Galvanism (positive pole over the motor points of the affected 
muscles, the negative pole to the periphery) has given relief in 
some cases. In the so-called "rheumatic" cases faradism and 
the application of dry heat ("hot ironing of the muscles") de- 
serve faithful trial. 

Aconite, Bryonia, Rhus, Gelsemium, Cicuta, Nux vomica, 
Strychnia and Belladonna should be studied. 

HYPOGLOSSAL NERVE. 

The hypoglossal nerve supplies the muscles of the tongue 
and the genio-hyoid muscle. Paralysis may result from bulbar 
disease, lesions cf the cortex, nuclear degeneration, degenera- 



DISEASES OF THE NERYES. 637 

tion of the nerve itself, compression from exudation, tumors, 
etc. The Symptoms of involvement of one hypoglossal are 
unilateral paralysis and marked atrophy of the tongue. The 
tongue, when protruded, turns toward the affected side. There 
are fibrillary twitchings of the muscular fibres and slight im- 
pairment of articulation. When bilateral (in bulbar paralysis; 
sometimes in progressive muscular atrophy), the tongue lies 
motionless on the floor of the mouth, rendering speech and 
mastication, and in part deglutition, very difficult. It is atro- 
phied when the seat of the disease is below the nuclei. The seat 
of the lesion can usually be determined; when supranuclear, 
there is hemiplegia and no atrophy of the tongue; nuclear le- 
sion, furthermore, is usually bilateral. Involvement of the 
fibres of the nerve within the medulla after they have left their 
nuclei may result in paralysis on one side of the tongue with 
paralysis of the limbs on the opposite side; the tongue, when 
protruded, is turned toward the sound side. 

Spasm of the tongue is rare. It occurs in chorea, epilepsy, 
spasm of the muscles of the face, and in hysteria. Cases of 
paroxysmal clonic spasms are on record in which the tongue is 
rapidly thrust forward and back forty, and more, times a 
minute. They usually recover. 

DISEASES OK THE SPINAS NERVES. 

CERVICAL PLEXUS. 

Occipitocervical neuralgia. (See article on "Neuralgia"). 

Affections of the Phrenic Nerve. — Paralysis may result from 
lesions in the anterior horns at the level of the third and fourth 
cervical nerves, from compression of the nerve, and from neu- 
ritis; it is usually bilateral. The result is paralysis of the dia- 
phragm. When the paralysis occurs suddenly, there may be 
temporary, but severe, dyspnoea and lividity. Otherwise the 
resulting disturbances are not great, since the abdominal mus- 
cles at once assume extra work. Upon exertion, dyspnoea is 
common. In case of bronchitis occurring simultaneously, the 
condition is dangerous on account of the added respiratory em- 
barrassment and the great difficulty of coughing, thus favoring 
the accumulation of mucus in the tubes. Unilateral paralysis 
rarely gives rise to marked symptoms, but its existence may be 



638 DISEASES OF THE NERVOUS SYSTEM. 

recognized from the inequality in the descent of the diaphragm 
on the two sides, the descent being less on the affected side. 
The prognosis is always serious. 

Spasm of the diaphragm may be tonic or clonic. Tonic 
spasm is rare; it occurs nearly always in connection with teta- 
nus, and is exceedingly dangerous. Relief must be afforded 
within a very few minutes, and to this end hot fomentations 
and inhalations of chloroform are advised. Clonic spasm 
(hiccough; singultus) is of common occurrence. It consists of 
intermittent, sudden contractions of the diaphragm which 
rarely persist long and are not accompanied with pain. Excep- 
tionally they are remarkably persistent, continuing for many 
days, and even weeks; in such cases all measures of relief may 
fail. A recent writer groups the cases into (a) inflammatory, 
chiefly seen in affections of the abdominal viscera and in severe 
forms of typhoid fever; (b) irritative, as from swallowing very 
hot substances; diseases of adjacent structures and gastric and 
intestinal disorders, more especially those associated with flat- 
ulency; (c) speciflc or idiopathic cases, in which there was no 
evident cause, but usually occurring with gout, diabetes or 
chronic nephritis; (d) neurotic cases (hysteria, epilepsy, shock, 
tumor). 

Treatment. — In light cases, common household measures, as 
holding one's breath, or drinking water, are usually quite suffi- 
cient. In serious cases, ice, salt and vinegar, or salt and lemon- 
juice may be tried. Lavage has been used successful^ in cases 
of gastric origin. Good results are claimed for the faradic 
brush freely emploj'ed over the diaphragm. Apomorphia (gr. 
2V), hypodermically, will cause copious emesis and may in a 
case of hysterical hiccoughing end the trouble. Pilocarpine, 
Amyl nitrite and Nitro-glycerine are recommended. Bartlett 
advises the study of Ignatia, Nux vomica, Cicuta, Stramo- 
nium, Arsenic, Pulsatilla, Hyoscyamus, Veratrum album 
and Kreosote. My own experience in nearly thirty years of 
active work embraces seven cases of unmanageable "hic- 
cough," two of them in old persons, one continuing for eleven 
days. Two cases passed out of my hands; of the other five cases 
one died ; one recovered after routine treatment embracing 
nearly every measure to be thought of; one was temporarily 
relieved by Ignatia and Asa fcetida, but began to gain and 



DISEASES OF THE NERVES. 639 

recover promptly under Moschus 2x; two received nothing but 
Moschus, without other attempts at relief, save bits of ice to 
relieve thirst, followed by improvement and recovery. 

BRACHIAL PLEXUS. 

This plexus of nerves supplies the muscles and skin of the 
upper extremities. All the nerves, or any of the nerves, compos- 
ing the plexus may be involved in disease and cause paralysis 
of the parts supplied; hence the paralyses here studied depend 
upon involvement of the entire plexus of nerves or upon lesions 
of the individual nerves of the plexus. 

Combined Paralysis. — The usual causes of paralysis are oper- 
ative here, of which compression of the nerve trunk and injuries 
are the most common; neuritis is rare. If the latter exists, it 
nearly always 'ascends from the periphery, gradually involving 
the entire limb. Injuries and blows on the neck frequently 
cause partial paralysis of the arm; here may be classed injuries 
occasionally received by the foetus during parturition. The 
most serious, and probably most common, form of combined 
paralysis is the result of luxation of the humerus, particularly 
the subcoracoid form, especially so when the luxation is not 
recognized, hence not reduced; the prolonged pressure upon the 
nerves results in permanent paralysis, with muscular wasting, 
reaction of degeneration, and trophic changes in the skin. 
Sometimes complete paralysis results from a fall or a blow 
upon the shoulder, seriously bruising the nerves, or from a dis- 
location of the humerus, though promptly and skillfully set. 

hong Thoracic Nerve. — This nerve supplies the serratus mag- 
nus. Paralysis of this muscle {serratus palsy) may result from 
neuritis due to exposure or, much more frequently, from in- 
juries in the posterior triangle of the neck, as from working 
"overhead" ("white- washing") or from pressure in carrying 
heavy burdens. It may occur in poliomyelitis and in progres- 
sive muscular atrophy. There may be neuralgic pain, espe- 
cially during the onset. The paralysis is easily recognized 
when the arm is moved forward; the paralyzed muscle is no 
longer able to hold the scapula firmly to the thorax, hence the 
scapula on the affected side appears "winged." 

Circumflex. Nerve. — This supplies the deltoid and the teres 
minor. The usual causes are operative. When there is loss of 



640 DISEASES OF THE NERVOUS SYSTEM. 

power in the deltoid, the arm cannot be raised; there is muscu- 
lar wasting, impairment of sensation in the skin over the mus- 
cles, and flattening of the shoulder. 

Musculo-spiral Nerve.— Owing to the exposed position of 
this nerve, paralysis here often results from injuries, blows, 
fractures, or from bruising the nerve in sleeping with the arm 
over the chair, or from prolonged use of crutches, or from 
sleeping, as many persons are fond of doing, with the head 
resting upon the arm. Rarely it results from neuritis (cold); it 
may be a feature of lead-poisoning. Wrist-drop and inability 
to extend the first phalanges of the fingers and thumb are char- 
acteristic. When the lesion is high up in the arm, the triceps, 
brachialis anticus and supinator longus are involved. In pres- 
sure palsy there usually is loss of power in the supinators. 
There often is tingling and impairment of sensation, but sen- 
sory disturbances are trifling. Pressure palsies may disappear 
in a few days, and eventual recovery may nearly always be ex 
pected. The treatment is that of neuritis. 

Ulnar Nerve. — This nerve supplies motor power to the ulnar 
halves of the deep flexors of the fingers, the muscles of the little 
finger, the interossei, the adductor and inner head of the short 
flexor of the thumb, and the ulnar flexor of the wrist. The sen- 
sory fibres supply the ulnar side of the hand, two and a half 
fingers on the back, and one and a half finger on the front. Par- 
alysis usually results from pressure at the elbow-joint. The 
hand moves toward the radial side ; the thumb cannot be ad- 
ducted, the first phalanges cannot be flexed, and the others can- 
not be extended. Long-standing cases present the "claw- 
hand." Loss of sensation occurs in the parts supplied by the 
sensory branches. 

Median Nerve. — This nerve supplies the flexors of the fingers, 
except the ulnar half of the deep flexors, the abductor and the 
flexors of the thumb, the two radial lumbricales, the pronators, 
and the radial flexor of the wrist. The sensory fibres supply 
the radial side of the palm and the front of the thumb, the first 
two fingers and half of the third finger and the dorsal surface 
of the same three fingers. Paralysis results from injury, some- 
times from neuritis, and is characterized chiefly by inability to 
pronate the forearm beyond the mid-position. The wrist can- 
not be flexed toward the radial side, and there is loss of power 



DISEASES OF THE NERVES. 641 

in the members supplied by the median nerve as above indi- 
cated. Marked wasting of the muscles of the thumb is charac- 
teristic and easily noticed. 

LUMBAR AND SACRAL PLEXUSES. 

Lumbar Plexus. — Lesions here usually arise in connection 
with psoas abscess, diseases of the vertebrae, and intra-abdom- 
inal growths. Involvement of the obturator nerve (sometimes 
from injuries during parturition) results in loss of rotation out- 
ward and loss of power to cross one leg over the other. In- 
volvement of the anterior crural nerve (dislocation of hip-joint, 
injuries, disease of the bones, psoas abscess, rarely during par- 
turition) results in paralysis of the knee, with wasting, anaes- 
thesia of the antero-lateral parts of the thigh and of the inner 
side of the entire leg. Involvement of the gluteal nerve results 
in loss of power of abducting the thigh. 

Sacral plexus. — Injury to this plexus is common from inflam- 
matory processes within the pelvis and during parturition. 
Neuritis also is of comparatively frequent occurrence here. In- 
volvement of the sciatic nerve at or near the notch causes 
paralysis of the flexors of the legs and of the muscles below the 
knee; when the point of involvement is below the middle of the 
thigh, only the muscles below the knee are paralyzed. There 
may be wasting and trophic changes. Sensory disturbances 
are: anaesthesia of the outer half of the leg, sole, greater part of 
the dorsum of the foot. In unilateral sciatic paralysis the 
patient walks with the affected leg flexed at the knee. In the 
rare paralysis of the small sciatic nerve there is difficulty in 
raising from a seat and anaesthesia of a strip along the back of 
the middle third of the thigh. The external popliteal nerve 
supplies the peronaei, the long extensor of the toes, the tibialis 
anticus, and the extensor brevis digitorum. In paralysis of 
these muscles there is foot-drop and "steppage" gait. If of 
long standing, there is permanent extension of the foot and 
wasting of the anterior tibial and peroneal muscles. Loss of 
sensation occurs in the outer half of the front of the leg and on 
the dorsum of the foot. Internal popliteal nerve. Paralysis 
results in loss of plantar flexions of the foot and of flexions of 
the toes, loss of abduction of the foot, loss of power in the 
41 



642 DISEASES OF THE NERVOUS SYSTEM. 

muscles of the sole of the foot. In old cases the position is that 
of talipes calcaneus, the toes assuming a claw-like shape from 
contracture. There is anaesthesia on the outer side of the sole 
of the foot. 

Sciatica and neuralgic affections of the nerves of the feet are 
discussed elsewhere. (See Neuralgia.) 

YASO-MOTOR A1VO TROPHIC DISORDERS. 

RAYNAUD'S DISEASE. 

An affection — probably a vaso-motor neurosis — which is com- 
posed of three stages, a stage of local syncope, a stage of local 
asphyxia, and a stage of local or symmetrical gangrene. 

Practically nothing is known of its aetiology save that it 
is seen oftener in persons of pronounced neuropathic tendency, 
especialh^ in women, and that it occurs usually during cold 
weather. Slight exposure and emotional excitement may pre- 
cipitate an attack. 

Its pathology is uncertain. According to Raynaud, who first 
described this disease, the local syncope is due to contraction of 
the vessels, involving the arteries, veins and capillaries; the 
asphyxia is caused by dilatation of the small vessels, with, pos- 
sibly, some spasm in the arterioles; necrosis arises from the loss 
of vitality of the tissues. 

Symptoms. — The onset of the local syncope usually is sudden 
and painless. One or more fingers, one or both hands, one or 
several toes, or the tip of the nose, or the tips of the ears, be- 
come cold, bloodless and of alabaster whiteness, sometimes a 
faint yellow; they feel stiff, and there is a loss of power of 
motion. After a time the color returns, frequently with con- 
siderable pain of a shooting or pressive character, and the parts 
assume their normal condition, or it progresses to local as- 
phyxia. This, the second, stage may also come on as the 
primary manifestation, and may involve any of the parts and 
members enumerated, including the trunk. The affected parts 
become livid, of a dark-purplish blue, or even black; when the 
finger is firmly pressed upon the cyanosed spot, the white mark 
thus produced remains for a long time, an evidence of the ex- 
tremely sluggish capillary circulation. There is usually some 
swelling and often severe burning pain, with periodical and 



DISEASES OF THE NERYES. 643 

intense aggravations. Marked anaesthesia is often present. 
Gradually the asphyxia passes off and the parts resume their 
normal state; in rather more severe cases slight loss of sub- 
stance is common. Such attacks may occur often and persist 
for a long time without injury to the health. If recovery does 
not take place, as in very severe cases, the coldness and insensi- 
bility of the parts persists, the pain usually increases, small 
blebs containing bloody serum develop on the skin, and slough- 
ing occurs. It is peculiar to this affection that nearly always 
the actual loss of substance is much less than the appearance 
of the involved parts would indicate. The formation of large 
symmetrical sloughs on the trunk or limbs, especially in chil- 
dren, is always to be dreaded, since they indicate the probability 
of a fatal issue within 'three or four days. In some cases the 
affected part, especially the fingers, toes, tip of nose or ear, 
become dry and mummified, a line of demarcation is formed, 
and the necrosed part is thrown off. 

It must not be inferred that these stages appear clear-cut 
and successively. They merely represent different conditions 
which may exist at the same time in the same patient and in 
the same member; thus the fingers of one hand may present the 
features of local syncope, local asphyxia and local gangrene. 

Associated with these symptoms there may be considerable 
malaise, loss of appetite, nausea, vomiting, colicky pain and 
diarrhoea. Hemoglobinuria may be present during an attack 
or in regularly recurring cases may take the place of an attack; 
sometimes there is albuminuria. Peripheral neuritis rarely 
occurs in connection with symmetrical gangrene. Urticaria, 
erythema nodosum and scleroderma have been noticed. 
Marked symptoms of cerebral involvement may be present, as 
torpor, tinnitus aurium, deafness, dimness of vision, narrowing 
of the retinal arteries, periods of unconsciousness, acute mania, 
and delusions. 

Local syncope and local asphyxia may recur for many years 
at stated times, proving a source of great annoyance and of 
considerable suffering; to these cases the term "chronic" has 
been applied. Chronic Raynaud's Disease does not end in gan- 
grene. 

Prognosis. — With the exception of the comparatively rare 
malignant type, there is slight danger to life. As pointed out, 



644 DISEASES OF THE NERVOUS SYSTEM. 

the loss of tissue is almost insignificant in the average case as 
compared with the threatening character of the local symp- 
toms which precede sloughing. 

Treatment. — The affected limbs should be raised and kept 
wrapped in cotton-wool. Barlow advises the use of galvanism 
early in the course of the disease. He immerses the affected 
limb in a basin filled with warm salt-water, into which the 
negative pole is placed, the positive pole being applied over the 
spine. In due time thorough rubbing in olive oil should be 
useful. Gangrene must be treated according to surgical princi- 
ples. 

Aconite, Belladonna and Glonoine, Secale, Lachesis, 
Crotalus and Arsenicum are the remedies suggested by the 
totality of symptoms. 

ANGIO-NEUROTIC CBDK9IA. 

An affection, probably of neurotic origin, which is character- 
ized by circumscribed oedematous swellings. It is also known 
as giant urticaria. A hereditar\' tendency appears well marked; 
the attacks often appear to be induced by indigestion and 
great mental excitement. The characteristic symptom sud- 
denly appears as a pale, circumscribed oedematous swelling, 
involving the skin and the mucous membrane, preferably on 
the face and eye-lids, also on the nose, lips, cheek, throat, back 
of the hands, legs, sometimes genitalia; these swellings vary in 
extent from two to eight inches; at times the raised spots are 
small, but soon they run together and cover a large area. Oc- 
casionally they occupy corresponding areas on both sides of 
the body. The outbreak may be preceded by intense redness, 
heat, itching, or by urticaria; occasionally well marked gastro- 
intestinal crises are observed in connection with the oedema; 
purpura is a rare symptom. Fatal results have followed sud- 
den oedema in the larynx. The attack rarely lasts long, usually 
passing off in a few hours. The affection is, however, exceed- 
ingly obstinate and may periodically recur for many years, as, 
in women, at the menstrual period. 

The treatment is purely symptomatic; among the remedies 
likely to be useful, Apis mellifica is the most promising. 



DISEASES OF THE NERVES. ' 645 



ACROMEGALY. 



A chronic affection characterized chiefly by enlargement of the 
hands, feet and face. Heredity seems an important factor. 
The disease usually begins from the twentieth to the twenty- 
fifth year, rarely earlier or later than the fortieth year. Women 
are attacked oftener than men. It is rare in America. The 
pathology of acromegaly is not understood. There is evidently 
a true hypertrophy of the bones, "which may also affect other 
parts, as the skin, connective tissue and blood-vessels. Ex- 
haustive study of the affection has been made by Marie, who 
considers it a dystrophy which bears to the pituitary body — 
which has always been found hypertrophied in acromegaly — 
the same relation which myxoedema bears to the thyroid 
gland; the correctness of this view is not established. 

Symptoms. — The hands and feet first begin to enlarge, the 
enlargement involving both the bone and the soft tissues; the 
wrists are markedly increased in size, but the arms are rarely 
affected. In the feet the big toe is especially involved; it ap- 
pears large, broad, and its nail is grooved vertically. The en- 
largement next involves the head and face, which, on ac- 
count of the involvement of the maxillary bones, especially the 
inferior maxillary, becomes elongated, broadened, and pro- 
truding in its lower part. The lips are thickened; the ears big 
and coarse; the teeth are widely separated and may drop out 
of the thickened alveolar process; the tongue becomes cumber- 
some and clumsy; the skull-bones grow thick. Gradually the 
bones of the trunk are involved, including the sternum, clavicle, 
and vertebrae, the implication of the latter resulting in marked 
kyphosis. 

There is no infiltration of subcutaneous tissue, but the skin 
may become coarse and flabby. The genitalia occasionally hy- 
pertrophy. Muscular wasting is not unusual. There is fre- 
quent, and occasionally intense and continuous, headache, with 
dimness of vision from progressive optic nerve atrophy, and 
more rarely diminution of the sense of hearing and smell. In 
women menstrual disturbances occur early; there may be com- 
plete suppression of the menstrual flow, with extreme dullness 
and apathy. The duration of the disease is from ten to twenty 
years, death usually resulting from cachexia. 



646 DISEASES OF THE NERVOUS SYSTEM. 

Diagnosis. — Acromegaly is to be differentiated from the 
osteitis deformans of Paget. In both the head is affected; but 
in acromegaly it is the facial, and not the cranial, bones, while 
in Paget's disease the cranial bones suffer most. In acrome- 
galy the face is egg-shaped, with the large end downward; in 
osteitis deformans the face is triangular, with the base up- 
ward; in acromegaly the shafts of the long bones, as a rule, 
escape; the reverse obtains in osteitis deformans. 

Marie has described under the name " osteo-arthropathie 
pneumique" an affection which in many respects resembles 
acromegaly. It is seen in persons suffering from lung-disease 
(purulent pleurisy-, chronic bronchitis, new growths), and is 
characterized by hypertrophy of the bones of the extremities 
and of the shafts, enlarged and bulbous phalanges, curved 
nails, and curvature of the spine. 

Treatment so far has proved wholly useless. O'Conner 
claims to have had good results from Sulphur and Silica. 

SCLERODERMA. 

A disease characterized by cirrhotic hardening of the skin 
and subcutaneous tissues, occurring in patches or in diffuse 
areas, and followed by atrophy. 

The aetiology is unknown. By far the greater number of 
cases observed occurred in women. Some cases seemed con- 
nected with rheumatic complaints. Usualh" it is attributed to 
exposure to wet and cold or to the prolonged immersion of the 
hands in cold water. The pathology is indefinite. The affec- 
tion is thought to be a tropho-neurosis, arising from changes 
in the arteries of the skin which eventually lead to connective- 
tissue overgrowth. 

Circumscribed scleroderma (Keloid of Addison; morphcea). 
The disease here occurs in patches, rarely larger than the hand; 
the skin in the affected part is hard, leathery, and of a waxy 
dead white. These patches may be situated along the course 
of a nerve of the trunk, intercostals, lumbar, or on neck, face, 
or breast; often they are surrounded by a narrow pink zone of 
dilated vessels. Usually the appearance of the patch is pre- 
ceded by lryperasmia, occasionally with pigmentation of the 
skin, accompanied with great itching and irritation, which 



DISEASES OF THE NERVES. 647 

ceases after the patch has become established. Anaesthesia is 
not uncommon later in the disease. The skin usually is ex- 
ceedingly dry. Sometimes the affection begins in a little white 
spot -which looks like cicatricial tissue. The circumscribed 
forms not infrequently exist with the diffuse type in the same 
person. 

The diffuse form is more likely to be ushered in with malaise 
and slight sensory disturbance in the parts to be affected; in 
due time the skin appears reddened and, usually, swollen, fre- 
quently not unlike erysipelas. After a period which varies from 
several days or weeks to one or two years, the skin becomes 
hard and tense, often with neuralgic pains in the parts, very dry, 
sometimes pigmented; there may be tenderness, but anaesthesia 
is much more common. When fully developed, the affected 
parts (extremities, face, the larger portion of the trunk) are en- 
cased in a hard, firm, unyielding armor of living tissue. The 
-wrinkles have disappeared; it is no longer possible to pick up the 
skin or to pinch it; if the face be involved, it is smooth, without 
expression or power of motion; even the movements necessary 
to chew the food maybe performed with the greatest difficulty. 
The joints are fixed, as though held in a vise, by the unyielding 
covering. There is little, if any, pain; itching is often ex- 
ceedingly troublesome at first, but it wholly disappears later. 
This state may exist for months or years, with periods of ar- 
rested development of the disease. Recovery, however, is very 
rare; death is usually due to intercurrent pneumonia or 
nephritis. 

Various diseases are so closely allied to scleroderma that 
they may be mentioned here. Sclerema neonatorum, is a con- 
genital affection or develops very soon after birth. It is char- 
acterized by areas of induration of the skin, which does not pit 
on pressure. It spreads rapidly and usually terminates fatally. 
CBdema neonatorum begins in the legs and rapidly invades 
the entire body. The skin is hard and stiff, but there is oedema 
of the subcutaneous tissues; hence, there is pitting from pres- 
sure and power to move the joints. Few cases recover. 

Sclerodactylia consists of deformity, shortening and atrophy 
of the fingers, the skin becoming thickened, waxy, sometimes 
pigmented. There is usually great deformity of the nails. 



648 DISEASES OF THE NERVOUS SYSTEM. 

Bullae and ulcerations are common. A striking feature is the 
remarkable sensitiveness of the patient to cold. 

Ainhum is a trophic lesion, peculiar to the negroes of Brazil, 
Africa and other tropical countries; it is confined to the toes, 
preferably the little toe, in which a furrow or band of in- 
durated tissue forms in the line of the digito-plantar fold. The 
slowly increasing constriction eventually results in the death 
of the toe, which drops off, frequently without previous pain 
or inflammation. 

The treatment of scleroderma consists largely of measures cal- 
culated to render the patient comfortable by clothing him 
warmly, for sensitiveness to cold is very pronounced; if pos- 
sible, he should spend the winter in a southern country. Gal- 
vanism is recommended by some writers; Blocq claims to have 
cured a case b}- electrolysis. Bartlett states that the remedies 
adapted to these cases are Bryonia, Guaiacum, Graphites, 
Hydrocotyle, Lachesis, Phosphorus, Silica and Stillingia. 

FACIAL HEMIATROPHY. 

This very rare affection, usually beginning in childhood, is 
probably due to involvement of the trophic fibres of the fifth 
nerve. It consists of progressive wasting of one side of the 
face, including the bones and the soft tissues. It results in 
startling as3'mmetry of the two halves of the face. There is no 
loss of sensibility on the affected side, but there may be pig- 
mentation of the skin and loss of hair and of the teeth (from 
destruction of the alveolar processes). Enfeeblement of the 
motor power is slight. The disease is slowly progressive and 
the prognosis almost hopeless. Clinical experience has been so 
limited that treatment must be considered experimental. 



PART IV. 



DISEASES OF THE MUSCLES. 



PART IV. 

DISEASES OF THE MUSCLES. 



MYOSITIS. 



Rheumatic myositis, i. e., muscular rheumatism, has already 
been considered. The true primary myositis (acute polymyo- 
sitis) is a rare affection, not yet understood. It is a disease of 
youth and middle age, occurs in an acute or subacute form, is 
probably due to some infectious agent not yet known, and grad- 
ually involves all the voluntary muscles of the body. It begins 
with pains in the extremities and trunk, accompanied with 
tenderness to pressure, some swelling of the muscles, and some 
loss of motor power. All these symptoms at first may be very 
slight. Later, especially when there is fever, the swelling be- 
comes more pronounced, oedematous, and there is a doughy 
''feel" to the muscles. The swelling is first seen on the extensor 
side of the extremities, then in the face and trunk. Involvement 
of the muscles concerned with deglutition and respiration even- 
tually takes place and constitutes a very painful feature of the 
disease. Enlargement of the spleen is common. Often an exan- 
them has been observed which is irregularly scattered over the 
body and limbs and leaves behind it a distinct pigmentation. 
Bronchitis and lobular pneumonia may occur in the course of 
the disease, and then the difficulty of expectorating plays a dis- 
tressing part. In some cases disorders of sensation have been 
observed, suggesting possible involvement of peripheral nerves; 
in others diffuse and extensive suppuration of the muscles has 
been seen. A suppurative form of myositis is also recognized 
which occurs in connection with pyeemia and some of the in- 
fectious diseases, as typhoid fever and influenza. 

Death often results within a few weeks, and then usually 



652 DISEASES OF THE MUSCLES. 

from paralysis of respiration. In other cases the course of the 
disease is slow, and exceptionally life is prolonged for two or 
three years; in these tedious cases atrophy of the affected mus- 
cles is not unusual. Opportunities for the study of myositis are 
very limited, so much so that even its clinical history cannot as 
yet be clearly outlined. 

The diagnosis is not especially difficult. Myositis closely 
resembles trichinosis, but any doubt can readily be solved by 
microscopic examination of bits of the muscular tissue. Mul- 
tiple neuritis, which it also resembles in many respects, lacks 
the oedematous character of the swelling. 

The treatment is symptomatic and supporting. 

Myositis ossificans progressiva is a form of inflammation of 
the muscles which usually occurs in men and the essential 
feature of which lies in progressive calcification or ossification 
of the affected muscular groups or areas, leaving the structures, 
after the inflammatory action has subsided, hard and bony. 
Practically nothing is known of the aetiology of the disease. It 
runs a tedious course, and so far has not responded to treat- 
ment. 



PROGRESSIVE MUSCULAR ATROPHY. 

A progressive atrophy of the muscular fibres, affecting groups 
of muscles, depending, not upon any affection of the nervous 
system, but upon primary' changes in the muscles. The disease 
is also known as Primary Myopathy, Idiopathic Muscular 
Atrophy, Primary Muscular D3^strophy, and Pseudo-Hy r per- 
trophic Muscular Paralysis. 

Etiology. — An inherited constitutional tendency is the only 
recognized ^etiological factor. The disease is usually trans- 
mitted through the mother, who herself ma}- not be affected. 
It may attack very young children, often about the time when 
they begin to walk, but more frequently just before puberty, 
more rarely at the twentieth 3 r ear or later. Bo3 r s suffer from 
it oftener than girls. 

Morbid Anatomy. — According to Erb, the primary change is 
hypertrophy of the muscular fibre. In the so-called pseudo- 



PROGRESSIVE MUSCULAR ATROPHY. 653 

hypertrophic form there is great increase of interstitial con- 
nective tissue and of the fatty tissue between the muscular 
fibres, giving to the muscle an appearance of enlargement and 
a soft, doughy feel. The fibres themselves may be normal or 
enlarged or atrophied; they are sometimes fissured longitudi- 
nally. The enlargement of the muscle as a whole is due almost 
entirely to an increase of the connective tissue and fat. In the 
atrophic form of the disease there may be at first some hyper- 
trophy of the muscular fibre, but atrophy is the essential feat- 
ure. There is a moderate increase of connective tissue, which 
is rich in nuclei and keeps pace with the atrophy of the muscular 
fibres. The fibre presents an increase of its nuclei and vacuola- 
tion. There are no lesions of the nervous system. 

Symptoms. — Various forms of this disease are recognized, but 
the clinical history of them all is much the same. The onset is 
gradual. The first thing to attract attention is clumsiness 
and awkwardness in the movements of the child, with evident 
insecurity on his legs; an examination reveals enlargement of 
certain groups of muscles, commonly the calves. Other muscles 
soon become involved, notably those of the trunk, back, loins 
and legs. Those usually affected are the extensors of the legs, 
glutei, lumbar muscles, deltoids, triceps, and the infraspinate; 
the muscles of the neck and face, including those of the tongue, 
pharynx, larynx and eye, almost always escape. The intrinsic 
muscles of the hands and the sphincters do not become atro- 
phied. As the result of these changes there is remarkable loss 
of strength in the back, loins and legs, rendering walking diffi- 
cult and waddling, and causing the child to stumble over the 
slightest obstacles. He stands with his feet apart, balancing 
the upper part of his body on the legs; the abdomen protrudes, 
the shoulders stand backward, and the spinal column in the 
lumbar region is arched strongly forward. To rise from a chair 
is laborious and requires the help of the hands, which are placed 
upon the knee or thigh or upon the arms of the chair. It is 
still more difficult to get up from the floor. To accomplish this, 
the child first gets up on hands and feet ("all fours"), then 
slowly raising the trunk by the use of the arms and gradually 
elevating the body by placing the hands upon the knees and 
moving them toward the body, using them as levers, "climbing 
up his leg." The weakness of the muscles of the shoulder is 



654 DISEASES OF THE MUSCLES. 

great; the shoulder is "loose," the blades project like wings, 
and when the arms are stretched out they appear of abnormal 
length; if the child is lifted by placing the hands under its arms, 
the shoulders are raised up to the level of the ears, and it seems 
as though the child would "slip through." The affected mus- 
cles continuously waste, all the traces of enlargement eventually 
disappearing; the patient finally becomes bed-ridden, and late 
in the course of the disease may suffer from contractures and 
deformities, such as spinal curvature and talipes. Throughout 
the course of the affection no characteristic sensory disturb- 
ances are noted; there is no reaction of degeneration, save in 
very exceptional instances; the mechanical excitability of the 
affected muscles is lowered, and the electrical reaction is weak- 
ened in proportion to the amount of fatty tissue present and 
to the degree of atrophy of the muscular fibre. It is claimed by 
some observers that thyroid enlargement and anomalies of the 
genitalia are not infrequently seen. 

The atrophic form differs from the preceding chiefly in the 
absence of primary pseudo-hypertrophy. Several t3^pes have 
been described, as those of Erb and of Duchenne. The former, 
know as the Juvenile form of Erb, usually declares itself from 
the eighteenth to the twentieth year of life, exceptionally later, 
and in man3^ cases first attacks the shoulders and arms, rarely 
first the back and legs. The symptoms are as described above, 
with especial prominence of the shoulder-blades. Erb states 
that the following muscles are almost always affected: the 
pectoralis major and minor, the trapezius, the latissimus dorsi, 
the serratus magnus, the rhomboidei, the sacro-lumbalis and 
longissimus dorsi, and later the triceps. Eventually the mus- 
cles of the back and legs are affected, the atrophy attacking 
chiefly the glutei, the quadriceps, the peronei and the tibialis 
anticus. The muscles here remaining intact longest are those 
of the forearm, except the supinator longus, and in the legs the 
sartorius and the muscles of the calf. Erb also calls attention 
to possible atrophic changes in the diaphragm, with resultant 
respiratory disturbances. 

In the Infantile type of Duchenne there is pronounced and 
sometimes primary implication of the muscles of the face, pre- 
venting perfect closure of the eyes and interfering with speech 
and pursing of the lips, as in whistling. 



PROGRESSIVE MUSCULAR ATROPHY. 655 

The so-called fades myopathique, a face void of expression 
and life, is the result of the wasting of the facial muscles. The 
affection after a time extends to the muscles of the shoulder 
and arm ("loose" shoulder) and may proceed further down- 
ward. The muscles involved in mastication remain normal. 
The intrinsic muscles of the hand, as already stated, remain 
normal in all the muscular dystrophies. As suggested by the 
name, this type is usually seen among young children; how- 
ever, exceptionally cases occur in which the first symptoms do 
not appear until the twentieth year. The course is chronic and 
the patient, here as in the other dystrophies, may for many 
years be able to be about; eventually he becomes bed-ridden 
and suffers from the contractures and deformities which belong 
to the entire group. 

The so-called Peroneal type of muscular atrophy (Charcot, 
Marie, Tooth) is no longer classed with any assurance among 
the myopathies. It is an affection of childhood, almost exclu- 
sively, and begins with wasting of the intrinsic muscles of the 
foot or of the peronei, extending upward into the thigh. It 
often results in deformity of the foot (club-foot). The course 
of the disease is very slow, but eventually it reaches the upper 
extremities, occasionally producing the claw-hand. It seems 
to follow certain acute diseases, notably measles, but heredity 
and family tendency play an important part. It differs from 
the myopathies in the presence, often, of fibrillary twitchings 
and of sensory disturbances, and in the order of attack seen in 
the involvement of the arm, the thenar, hypothenar and inter- 
ossei being first affected. The reaction of degeneration may be 
present. It is probable that this affection is of neurotic origin. 

Diagnosis. — The pseudo-hypertrophic form is easily recog- 
nized, chiefly from the contrast, even in the early stage, be- 
tween the large size of the muscles and their great lack of 
strength. If the loss of muscular power results from cerebral 
disease, it almost always occurs in the form of a monoplegia, 
followed by atrophy of the affected muscles. If of spinal 
origin, there are present: fibrillary contractions in atrophied 
and non-atrophied muscles, reaction of degeneration, fre- 
quently marked spastic conditions in the legs, and increase in 
the reflexes; the disease appears late in life and heredity plays 
no part. — Chronic anterior polyo-myelitis usually begins in 



656 DISEASES OF THE MUSCLES. 

the small muscles of the hand. — The atrophies of neuritic origin 
are characteristic in their distribution, in their marked loss of 
muscular power as compared with the extent of the wasting, 
in the absence of any indication of heredity, and in the peculiar 
gait in case the legs are involved. 

The course of the muscular dystrophies is very tedious, and 
the prognosis unfavorable. 

Treatment, so far, has done little or nothing to arrest the 
disease. Erb speaks encouragingly of the use of electricity, but 
in the main its employment has proved unsatisfactory. Better 
results have been obtained by massage practiced for a long 
time and with great gentleness, especially when olive oil is freely 
used. Moderate and systematic exercise is of service. Much 
relief, in a negative way, may be afforded by such attention 
in the late stage of the disease as will prevent the occurrence of 
contractures in awkward and painful positions. Clarence 
Bartlett suggests the long-continued internal use of Potassium 
iodide, from fifteen to thirty grains daily, and of preparations 
of gold, because of the influence which these drugs exert over 
fatty degeneration and connective tissue overgrowths. I am 
not aware that positive results have been obtained under 
strictly homoeopathic medication, but Phosphorus, at least, 
deserves careful study. 



THOMSEN'S DISEASE. 

Thomsen's disease, myotonia congenita, is a rather rare dis- 
ease, especially in America, where only a few cases have been 
observed; the majority of cases seen have occurred in Scandi- 
navia and Germany. It consists of tonic contractions of the 
voluntary muscles, chiefly of the arms and legs, rarely of the 
face, larynx or eye. Nothing is known of its aetiology, save that 
heredity appears a most prominent factor, almost all the cases 
so far observed having occurred in family groups. 

Symptoms. — The disease comes on in childhood, the first 
symptoms consisting of awkward stiffness and rebelliousness 
of the voluntary muscles, nearly always of the arms and legs, 
particularly noticeable when the first attempt at a voluntary 



PARAMYOCLONUS MULTIPLEX. 657 

movement is being made; the stiffness gradually disappears 
when the effort is continued, but recurs when renewed after a 
rest. Thus the child, when attempting to walk, can only with 
considerable difficulty raise and put forward the leg, and the 
action itself appears ungainly and stiff; the effort continued, the 
movement becomes easier, and after a time apparently natural; 
but after resting, the same difficulty is experienced. The arms 
and hands behave in the same manner, rendering the move- 
ments of the child uncertain and giving rise to many accidents 
and annoyances. There is no pain, and the sensations and re- 
flexes are normal. The muscles themselves are well-nourished, 
sometimes rather large; in some cases there is considerable 
muscular force, while others present decided loss of muscular 
power. A tendency to hypochondria or mental weakness has 
been observed. Aggravations occur from cold and emotional 
excitement. Erb's so-called myotonic reaction consists of slow- 
ness of muscular contraction and relaxation under electric 
stimulation and the passing of wave-like contractions from 
the cathode to the anode. Excision of bits of the affected mus- 
cle have shown great enlargement of the voluntary fibres. 

The disease is not curable under any known treatment, but 
gentle and systematic exercise is probably beneficial. It per- 
sists throughout life and may eventually become quite general. 
Temporary arrest of the affection or at least marked temporary 
improvement is not unusual. 



PARAMYOCLONUS MULTIPLEX. 

An affection, first described by Friedreich, which consists of 
clonic contractions, principally of the muscles of the leg, occur- 
ring in paroxysms. The nature of the disease and its cause is 
not understood. It is usually seen in male adults of a nervous 
temperament, and seems frequently to result from fright or to 
be closely related to hysterical or choreic conditions. It is pos- 
sible that the affection is in reality a disease of the nervous 
system, and Tambroni and Pieracini have placed on record 
several cases depending upon organic lesion of the nerve centres. 

The symptoms consist of clonic spasms which usually begin 
42 



658 DISEASES OF THE MUSCLES. 

in the muscles of the legs, are generally bilateral, frequently 
number from one hundred to one hundred and fifty in the 
minute, often distinctly rhythmical. Tremors between the 
attacks are common. At first the affection does not seriously 
interfere with the patient's daily occupation, but eventually 
the muscles of the back and abdomen may become involved, 
and the patient is rendered helpless from the violence of the con- 
tractions. 

The course is prolonged, recurrences frequently taking place 
after an interval of years. In a majority of cases the patient 
finally recovers. 

The treatment is that of neurasthenia and hysteria. Strong 
currents of electricity are highly recommended. 



PART V. 

INTOXICATIONS, HEAT-EXHAUS- 
TION, OBESITY. 



PART V. 

Intoxications, Heat-Exhaustion, 
Obesity. 



ALCOHOLISM. 



Acute Alcoholism or Drunkenness. — The symptoms of acute 
alcoholism are familiar to all and need not be described here. 
It is, however, well to point out their close similarity to ap- 
oplexy, and the necessity of caution in differentiating between 
these two conditions, for mistakes are by no means infrequent. 
In apoplexy the unconsciousness of the patient is much more 
profound; breathing is stertorous; there may be hemiplegia, 
and there is an absence of alcoholic odor about the breath. 

Chronic alcoholism results from the long-continued and im- 
moderate use of alcoholic stimulants and their effects upon the 
system at large, especially upon the digestive and the nervous 
system. That the poisonous action of alcohol is far-reaching 
and diversified, is evident from the fact that it is closely con- 
nected with the aetiology of very many diseases discussed in the 
body of this book. It is probable that the general tissue 
changes produced under its influences are due to (1) the action 
of the poison upon the blood, which it impoverishes and whose 
power of oxygenation it lessens materially, (2) its direct action 
as an irritant upon the tissues with which it is brought into 
contact, and (3) its effects upon the nervous system, causing 
motor paralysis and impairing reflex action. 

The digestive system usually suffers first. A gastric catarrh 
develops, more or less intense, with derangement of appetite, 
dryness of the mouth, lips and tongue, furred tongue, and a 
tendency to constipation. A marked symptom is the faintness 
and sense of gastric emptiness and goneness at the stomach 



662 INTOXICATION, HEAT-EXHAUSTION, OBESITY. 

from which chronic alcoholics suffer so much, especially in the 
morning, and which by its prompt disappearance under a 
renewed dose of, the stimulant becomes a potent agent in hope- 
lessly fixing the habit. In the nervous system a group of 
symptoms appears which in many respects suggests neuras- 
thenia. The time of their appearance varies and depends 
largeW upon the presence or absence of a neurotic tendency in 
the individual. A certain, and often very marked, unsteadiness 
of the muscles is usually the first indication of beginning 
trouble, followed by tremors which are especially noticed in 
the hands and tongue, less pronounced in the legs. The mental 
faculties become weakened, and the patient himself is quite 
conscious that he needs the stimulation of a drink to steady 
himself and become fit for the common duties of the day. He 
is slow to think, undecided in action, irritable and peevish, 
loses his ideality, cannot reason correctly, and gradually de- 
scends to a lower plane of life and action than that formerly 
occupied b}- him. Of this fact he is for a long time conscious, 
and suffers keenty from the knowledge, but unless possessed of 
a powerful will he drifts with the current, and eventually recon- 
ciles himself to the seemingry inevitable. His sleep in the mean- 
time has grown unrefreshing, often full of unpleasant dreams and 
frequently disturbed by muscular tw.itchings; in the morning he 
awakens tired, out of sorts, despondent, "gone" and faint at 
the stomach, and with intense craving for the renewed stimula- 
tion. In the meantime the peripheral nervous system has 
broken down, a multiple neuritis occurring in a large number 
of cases, extending from the periphery to the centre, with dis- 
turbances of sensation which may consist of painful hyperes- 
thesia, a diminution of sensation, or morbid sensations (as 
though ants were crawling over his bod} r ). Epileptiform con- 
vulsions have also been noted. Perhaps the most striking 
symptom of this process of degeneration is the constantly de- 
creasing stability of mind, the loss, eventually, of all apprecia- 
tion of propriety, honor, and a progressive and very notable 
impairment of will-force. 

The outcome of it, in many cases, is alcoholic insanity. This 
is frequently foreshadowed by increasing and fixed despondency, 
with a suspicious attitude toward all who are about and asso- 
ciated with the patient. This suspiciousness finally becomes 



ALCOHOLISM. 663 

the basis of hallucinations of both sight and hearing, with 
delusions of persecution. The mental condition now is one of 
great despondency and constant fear, and may lead to the com- 
mission of crime as a means of escape from torture or an act of 
self-defence. Exceptionally, notions of aggrandizement and ex- 
altation, with religious hallucinations, prevail. Spitzka states 
that delusions of alcoholic insanity almost always relate to the 
sexual organs, to the sexual relation, or to poisoning, and this 
is substantiated by many alienists. In some cases alcoholic 
insanity is sudden in its onset, assuming the initial form of an 
attack of delirium tremens, without recovery from the par- 
oxysm. In some instances a victim of alcoholic mania, when 
not under the influence of alcohol, may be peaceable and to all 
intents and purposes fully responsible for his actions, but be- 
come a raving madman as soon as he has taken a drink. The 
organic changes in the nervous system are those of a low grade 
of inflammation and resemble those arising from old age and 
wasting diseases. 

Cirrhosis of the liver is a conspicuous feature of chronic alco- 
holism. It is now held that a natural tendency to this condi- 
tion is an important factor, and that in the absence of it many 
confirmed drunkards develop no symptoms of it. The kidneys, 
according to hospital statistics, are usually somewhat en- 
larged. The enlargement of the venules of the face, particu- 
larly of the nose, the coarseness of the face, the watery eyes, 
and the "pimples" of the drunkard — acne rosacea — are among 
the common and familiar minor results of chronic drunkenness. 

Delirium Tremens or Mania a Potu is to all intents and pur- 
poses an acute attack of alcoholic mania which occurs in con- 
nection with chronic alcoholism. Persons of temperate habits 
are not liable to such an attack, even though they may have 
indulged in a severe and protracted debauch; it is the 
habitual drunkard who furnishes the victim. It is stated upon 
good authority, and the statement is accepted by many, that 
the sudden withdrawal of alcohol in an alcoholic may give 
rise to delirium tremens; but such attacks, so far as my expe- 
rience goes, more truly resemble a prolonged period of intense, 
hysterical nervous excitement, with only moderately pro- 
nounced characteristics of alcoholic poisoning. 

In nearly all cases restlessness, uneasiness, despondency, ap- 



664 INTOXICATION, HEAT-EXHAUSTION, OBESITY. 

prehensions of trouble, and insomnia are prodromal symptoms, 
continuing for a period of two or three da3 r s before the delirium 
declares itself. The restlessness increasing, the patient grad- 
ually losesjcontrol of himself, becomes incoherently talkative, 
and insists upon getting to his business or expresses a determi- 
nation to attend to some imaginary, urgent affair which re- 
quires his presence. Muscular tremors are frequent, especially 
of the hands; they are much aggravated from attempted vol- 
untary movements. The delirium itself is characterized by 
fearfulness; even before the delirium has declared itself the pa- 
tient often suffers from apprehension of danger, and frequently, 
in spite of a guarded exterior and of great efforts to hide his 
mental condition, his actions betray him. In the delirium hal- 
lucinations of sight and hearing, especially the former, torment 
him. He sees disgusting and horrible objects all about him; 
mice, rats and snakes run or crawl about his room, bed, or 
person, and threats and insults proceed from the voices of in- 
visible persons. This results in paroxysms of uncontrollable 
rage and fear during which the patient endeavors to make his 
escape through doors or windows, and will not hesitate, even 
though naturally of a peaceful or timid disposition, to at- 
tack his attendants, whom he fancies in league with his 
persecutors. The delirium is at first worse during the night 
and lighter during the day, but soon it becomes constant. Ac- 
companying symptoms are: rapid, weak, compressible pulse; 
elevation of temperature, ranging from 101° to 103°, and 
higher when there are complications or the case is unusually 
severe; complete loss of appetite; copious sweating; scanty, 
albuminous urine. 

In light cases the patient after a few days falls into a pro- 
longed sleep, to awaken refreshed and on the road to rapid re- 
covery. In others, sleep returns gradually, the hallucinations 
become less persistent, the moral tone improves, there is some 
relish for food, and gradually a normal state is regained. On 
the other hand, delirium may continue indefinitely and termi- 
nate in alcoholic insanity; or the nervous symptoms increase in 
intensity, sleeplessness persists, and the condition soon resem- 
bles the typhoid state, with extreme prostration, exceedingly 
rapid and weak pulse, dry cracked tongue, with evident ten- 
dency toward a fatal termination, death occurring from heart 
failure. 



ALCOHOLISM. 665 

The action of alcohol upon the kidneys and liver is at times 
very severe and renders the prognosis more serious than it 
otherwise would be. Pneumonia also is not uncommon, and 
must be looked for in cases of known exposure to cold; since 
the signs here may not be well marked, repeated examinations 
of the chest must be made. 

Recovery is the rule in the first attack, but the prognosis 
must be more guarded with each recurrence and in the presence 
of the complications described, especially pneumonia. 

The diagnosis of delirium tremens is rarely difficult. It de- 
pends chiefly upon the history of the case, the character of the 
delirium, in which fear strongly predominates, and the pres- 
ence of tremors. It is necessary to watch for complications 
and to guard against overlooking the existence of some injury, 
since it is a well-established fact that even a trifling hurt may 
in a chronic alcoholic precipitate an attack of delirium tremens. 
In case of pneumonia involving the apex of the lungs, the de- 
lirium often bears a striking resemblance to that of mania a 
potu, but the delirium of pneumonia is more aggressive and 
has no tremors. 

Treatment. — Acute alcoholism requires little attention. 
Nearly always a profound sleep prevails from which the pa- 
tient awakens refreshed and "quite himself." In exceptionally 
violent cases the hypodermic injection of one-eighth to one-sixth 
of a grain of apomorphia is very useful; it causes free emesis, 
lessens the delirium, and does much toward sobering the vic- 
tim. Thorough washing-out of the stomach is advisable when 
the nervous system suffers severely. Occasionally there is 
marked collapse, in which case brisk rubbing of the body and 
hot applications are useful. In the rare cases characterized by 
convulsions, chloroform may be used, but with caution. Hav- 
ing recovered from the immediate effects of a debauch, pains 
must be taken to protect the victim from an early repetition of 
it. An abundance of nourishing liquid food should be given, 
and quiet and rest be insured. The Turkish bath is a valuable 
auxiliary at this time and assists in getting rid of the last 
traces of alcohol in the system. 

Chronic alcoholism first of all demands absolute withdrawal 
of the poison. This can best be accomplished by placing the 
patient in some institution where he is not only beyond actual 



666 INTOXICATION, HEAT-EXHAUSTION, OBESITY. 

temptation or power to indulge himself, but can be managed 
with judicious firmness, should necessity arise. Sleeplessness 
and nervous tension are sure to prove stubborn and must be 
overcome, the former b}^ the prudent use of bromides or hyos- 
cine hydrobromate, the latter by enforced quiet and nourish- 
ing diet, chiefly milk. It is useless to deny the absolute neces- 
sity of occasionally using hypnotics, and sometimes in large 
doses; but it is a very serious blunder to resort to them upon 
slight temptation. During this time of great trial it is well to 
allow the patient an occasional cup of good, strong coffee and 
to season his food generously. For the latter purpose red 
pepper is invaluable. It supplies to the enervated gastric mu- 
cous membrane a substitute for the alcohol to which it is 
accustomed, increases the relish for food, and is altogether 
grateful to the patient. Occasional doses of from twenty to 
thirt}^ drops of the tincture of capsicum will give tone to the 
stomach and lessen the craving for drink. 

The exhibition of Arsenicum, Hydrastis, Xux, Strychnia, is 
very often demanded by the symptoms present. Their relation 
to the digestive organs, especially the stomach, and to the 
nervous system is well understood, and S3 r mptomatic indica- 
tions need not be given here. Hydrastis has proved very ser- 
viceable in rrn- hands, especially in the relief of the gastric catarrh 
of chronic alcoholism, with "faintness" at the stomach and in- 
tense craving for stimulants. Arsenic has done best in trit- 
urations ranging from the third decimal to the twelfth, while 
Hydrastis and Xux should be given in almost physiological 
doses. 

Delirium Tremens. — The patient must be kept in bed, in a 
quiet room, protected against intrusion, guarded against ex- 
citement of any form and possible escape. To accomplish the 
latter, the doors and windows must be securely fastened, espe- 
cially if the sick-room is up-stairs, and constant watch upon 
the patient must be kept both day and night. It is not well to 
strap him to the bed if it can be avoided, as may often be done 
by an attendant of experience in the management of such cases, 
but if force must be employed to restrain the patient, it is far 
better to use a strong sheet thrown over him and fastened at 
the sides, or even a strait-jacket, or sort, leather hand-cuffs, 
than to allow a series of hard struggles between him and the 



LEAD-POISONING — PLUMBISM— SATURNISM. 667 

nurses. Alcohol should be withdrawn at once, unless there is 
danger of heart failure. One of the most important objects of 
treatment is to insure sleep, and to that end hyoscine hydro- 
bromate, not to exceed T ^ ¥ part of a grain, may be given. 
Chloral (15 to 20 grains) is in favor with many practitioners 
of experience; it is unsafe if the action of the heart is feeble. 
The wisdom of giving opium here is doubtful; if used at all, it 
must be administered in the form of hypodermic injections of 
morphia, and its effects are to be carefully noted. The free use 
of the warm pack may prove of great advantage in quieting 
the patient and inducing sleep. If there is much fever, the cold 
pack may be employed, aided by the exhibition of Aconite, 
Belladonna, Gelsemium, or any other remedy which is indi- 
cated. Hot fomentations to the loins and hot sitz-baths are of 
value when there is suppression of urine. Should heart-failure 
threaten, alcohol with spirits of ammonia is preferable to digi- 
talis, which, as demonstrated by experience, must here be given 
in very large doses to accomplish its purpose. 

Especial attention must be paid to the diet. It is of the 
utmost importance that the patient's strength be sustained, 
and to this end milk or concentrated meat broths, with egg- 
albumen, are to be given every three hours. Here also it is well 
to season very highly with red pepper. Predigested foods may 
be used to advantage; feeding per rectum may be demanded. 

The remedies most likely to prove of value are Belladonna 
(sleeplessness especially prominent), Hyoscyamus (convulsive 
action pronounced), and occasionally Stramonium (incessant 
talking). Agaricus, Cannabis Indica, Cimicifuga, Gelsemium 
and Opium are frequently useful. 



LEAD-POISONING— PLUMBISM— SATURNISM. 

Lead-poisoning is common throughout the civilized world. 
It results from the introduction of lead into the system, usually 
in the pursuit of an occupation (painters, printers, workers in 
white-lead factories, plumbers, glaziers, etc.) which involves 
handling of lead and exposure to its action. In persons who 
are not thus employed poisoning may be due to the use of 



668 INTOXICATION, HEAT-EXHAUSTION, OBESITY. 

drinking-water stored in cisterns lined with lead or conducted 
through lead pipes, or of sour wines or acidulated drinks (espe- 
cially when sold in siphons provided with lead tips ) which have 
come in contact with lead; less often, and yet not infrequently, 
specific toxic effects are caused by lead contained in hair-dyes, 
false teeth set on cheap plates, and other articles containing 
lead which are in daily use. Lead enters the system through 
the digestive organs, lungs, and skin; it is eliminated by the 
kidneys and skin. Persons between 30 and 40 years of age 
furnish the larger percentage of victims, but no age is exempt. 
Women are more susceptible to it than men. Individual sus- 
ceptibility is an important item; in some cases violent S}^mp- 
toms occur from slight exposure, while others suffer very little 
from constant handling of dangerous articles. 

Acute lead-poisoning- finds its typical expression in the so- 
called lead-colic (colica pictonum), which is commonly seen in 
workmen employed in handling lead or its compounds. The 
attacks are frequently preceded by malaise. Colic develops 
rather suddenly, accompanied with loss of appetite, whitish 
and contracted tongue, sickness at the stomach, severe retch- 
ing and vomiting, intense thirst and stubborn constipation. 
The colic is constant and the pain dull and heavy, "with recur- 
ring paroxysms of severe aggravation, with sharp and twist- 
ing pain, preferably near the umbilicus. A characteristic 
feature is the hard, rigid, knotted, retracted condition of the 
abdomen. The pain is usually relieved from hard pressure. 
During the severe paroxysms the pulse increases in tension and 
the action of the heart is somewhat retarded. The pupils fre- 
quently are unequal. Often the patient complains of neuralgic 
pains in the chest and extremities, and there may be jaundiced 
coloring of the conjunctiva. In another type of cases, also 
seen among workers in lead, the symptoms are more intense 
and the nervous system suffers more severely. There is in some 
rapidly developing anaemia. A true, often rapidly fatal, 
gastro-enteritis prevails in others. Or the case assumes the 
form of an acute neuritis, with convulsions, possibly of an epi- 
leptiform character, and marked delirium. Mackenzie states 
that acute lead-poisoning is more frequent in winter than in 
summer. 

Chronic lead-poisoning constitutes an exceedingly complex 



LEAD-POISONING— PLUMBISM— SATURNISM. 669 

and varied group of conditions. Anaemia is one of its common 
and, usually, earliest features. It is rarely profound, the cor- 
puscles not often sinking below fifty per cent. The character- 
istic blue line along the gums is typical. It consist of a blue- 
black line at the margins of the gums, which results from the 
absorption of lead into the tissues and its conversion into a 
black sulphide. It may form quickly, disappearing after a 
few weeks, or it may remain for a considerable length of time. 
The gum itself is irregular in outline, receded from the teeth 
and ulcerated. This line must be distinguished from a line on 
the gums, also common, which may be easily wiped off or re- 
moved by brushing. Lead-colic is frequent and does not differ 
from the attacks already described. 

Of particular interest are the direct effects of lead-poisoning 
upon the nervous system, there giving rise to palsy affecting 
different groups of muscles (localized palsy) or general paraly- 
sis. Of the former, the so-called wrist-drop is the most charac- 
teristic and clinically the most important form. It affects both 
wrists, first the wrist of the arm most used, and is due to par- 
alysis of the extensor muscles of the hand. It is followed by 
atrophy of the affected muscles, with eventually great diminu- 
tion and even complete loss of electro-contractibility. The fol- 
lowing localized forms are recognized by Madame Dejerine- 
Klunipke: The ante-brachial type, involving the extensors of 
the wrist and fingers, causing wrist-drop, atrophy, sometimes 
swelling over the wrist from displacement backward of the 
bones of the wrist-joint and distension of the synovial sheaths. 
The brachial type, which usually is secondary to the ante- 
brachial type, but may be primary. It involves the deltoid, 
biceps, brachialis anticus, supinator longus, sometimes the pec- 
torals. The paralyzed muscles atrophy. The Aran-Duchenne 
type, sometimes primary, often seen in tailors (Moebius), in- 
volving the small muscles of the hand and of the thenar and 
hypothenar eminences. Marked atrophy, according to Gowers, 
occurs simultaneous with the palsy. Peroneal type, involving 
the lateral peroneal muscles, the extensor communis of the 
toes, and the extensor proprius of the big toe, causing the so- 
called "steppage gait." The laryngeal form, resulting in ad- 
ductor paralysis. 

Generalized palsies, usually beginning with wrist-drop, grad- 



670 INTOXICATION, HEAT-EXHAUSTION, OBESITY. 

ually involve all the extremities, their course being essentially 
chronic; in other cases all the muscles of an affected part be- 
come involved with great rapidity. Exceptional forms have 
been described, as the case reported by Oliver in which complete 
paralysis of a large area of muscles took place within a very 
short time, even a day. Others bear close similarity to sub- 
acute spinal paralysis; and in still others there has been in- 
volvement of muscles which are rarely affected, as the dia- 
phragm. In all these types of paralysis the onset of the 
affection may be, and usually is, marked by sharp neuralgic 
pains in the legs and joints (saturnine arthralgia); there are, 
later on, twitchings of muscles, sometimes cramps (calves), 
tremors, wasting of affected muscles, following the palsy or 
developing with it, frequently reaction of degeneration, and 
usually loss of response to electric stimulation. Sensation may 
be normal. 

The brain-symptoms are varied. In addition to the hysteri- 
cal and neurasthenic conditions which are found with especial 
frequency in girls, there are tremors, sensory and motor dis- 
turbances of cerebral origin, insomnia, convulsions which may 
be epileptiform or alternated with or followed b}- trance, epi- 
lepsy, delirium with hallucinations, coma, and, exceptionally, 
insanity, usually melancholia. Cases have been reported which 
bear a close resemblance to the general parah-sis of the insane. 
Optic neuritis, neuro-retinitis, atrophy of the optic nerve, palsy 
of the ocular nerves and laryngeal palsy may also be the result 
of lead-poisoning. 

In addition, arterio-sclerosis with contracted kidney and 
cardiac hypertroplry is relatively frequent among lead-workers. 
Gouty deposits, especially in the big toe, are common in Eng- 
land, much less so in America. In women, menstrual derange- 
ments and ovarian or uterine disease frequently results from 
lead-poisoning, with a strong tendency to abort in case of 
existing pregnancy. 

The prognosis is nearry always favorable, provided the sub- 
ject can be protected against further exposure. Wrist-drop is 
often permanent. Extensive atrophy of palsied muscles rend- 
ers recovery improbable. Violent convulsions are unfavorable. 

The diagnosis is not difficult, for there is usually a history of 
exposure, with such characteristic symptoms as the presence of 



MORPHINISM — MORPHIOMANIA. 671 

the blue line on the gums or lead colic or palsy. If, as some- 
times happens, a diagnosis cannot readily be made, the presence 
of lead in the urine must be established by tests, for which 
consult special works; they are delicate and had better be left 
to an experienced chemist. Iodide of potassium stimulates the 
elimination of lead by the kidneys; it is, therefore, well to place 
the patient under its influence before testing the urine. 

Treatment. — Perfect cleanliness of the hands and finger nails, 
frequent bathing and the use of respirators constitute the most 
important prophylactic measures within easy reach of persons 
obliged to work in lead or its compounds. An attack of lead- 
poisoning having been experienced, the prevention of further 
exposure is, of course, the most essential condition to a cure. 
Elimination of the poison by the kidneys is all-important and 
can be insured by the exhibition of iodide of potassium, in doses 
of five to ten grains, three times daily. The bowels, in the 
meantime, should be kept open, and to this end salts or appro- 
priate mineral water may be used. Massage, systematically 
employed, also has a high reputation for aiding in the elimina- 
tion of lead. Lead-colic requires hot applications and opium. 
The hypodermic use of morphia is a common practice, though 
open to the restrictions which apply to this method of relieving 
pain. Lilienthal advised the rapidly alternated use of a towel 
wrung out of ice-cold water over the entire surface of the abdo- 
men, to be retained for a few seconds, and of a nearly burning 
dry napkin. 

The following remedies are indicated: Opium, Nux vomica, 
Arsenicum, Belladonna, Alumina. The constipation of lead- 
poisoning is best met by Opium or Nux vomica, aided by a 
strong interrupted current through the abdomen, used daily in 
brief seances. The palsies require massage and the persevering 
use of the constant electric current. 



IHORPHINIS1H.-MORPHIOMANIA. 

The victims of the morphine habit are almost invariably per- 
sons, usually women or medical men, who are great sufferers 
from some painful disease, such as sciatica; the relief from pain 
obtained by taking the drug establishes the habit. The doses 
are gradually increased, not as a matter of choice, but of neces- 



672 INTOXICATION, HEAT-EXHAUSTION, OBESITY. 

sity, and no harm seems to follow; after a time, varying greatly 
in different persons, the patient is unable to get along without 
the drug, experiencing an uncontrollable desire for it and a 
sense of keen discomfort and nervousness when not under its 
influence, all promptly relieved when the craving for morphine 
is satisfied. This condition marks the beginning of morphinism. 

The symptoms which now develop vary in different persons, 
but their totality always constitutes a state of great physical 
and mental wretchedness. There is extreme lassitude and de- 
pression of body and mind. The appetite is lost, and nausea, 
epigastric uneasiness and faintness, sometimes acute pain, 
are persistent, but are promptly relieved when morphine is 
taken. A settled restlessness takes hold of the patient; he can- 
not content himself anywhere, keeps constantly on the move, 
grows morose and irritable, and can no longer find refreshing 
sleep. The pupils often are unevenly dilated when not under 
the influence of the drug; there is in many cases uncontrollable 
itching of the skin, and occasionally spells of profuse sweating, 
preceded by chilling, which bear some resemblance to malarial 
fever; elevation of the temperature, as high as 104°, has been 
noted in this connection. The nervous symptoms resemble 
those of hysteria and neurasthenia. The mental condition is 
characteristic. The patient is suspicious of everybody and 
thinks himself the object of all kinds of persecution; moreover, 
he is sure to become an inveterate liar upon whom no depend- 
ence whatever can be placed. The utter instability of the 
morphine fiend is remarkable. In some cases the mind dwells 
much upon sexual matters, and suspicion of unfaithfulness on 
part of a companion is quite a common occurrence. The ap- 
pearance of the patient is drawn, haggard, thin, sallow and 
prematurely aged. A profound asthenia finally prevails, the 
subject becomes wholly unmanageable, refuses to take nour- 
ishment, and dies from exhaustion. 

The prognosis is serious, because the greater number of 
patients, even after the habit has been broken, relapse sooner 
or later. In those of strongly marked neurotic tendency and 
in persons who continue to suffer from severe pain, due to an 
incurable disease, the outlook is exceedingly discouraging. 
These facts should be sufficient to make medical men hesitate 
before they allow their advice to pave the way for the establish- 



MORPHINISM— MORPHIOMANIA. 673 

ment of this frightful drug-disease, especially when they con- 
sider that according to statistics morphinism appears to be on 
the increase and that the medical profession from its own 
numbers furnishes many victims. 

Treatment. — The nature of the affection is such that a great 
deal more can be accomplished in an institution, such as a State 
hospital, than at home. The chief indications are: rapid with- 
drawal of the drug and supporting treatment. To accomplish 
this, the patient must be put to bed for at least ten or twelve 
days, isolated from all save the necessary attendants, and sur- 
rounded by nurses who can neither be coaxed nor bribed into 
supplying the patient with morphine. Whether, or not, it is 
best to withdraw the morphia at once, or rapidly, or gradually, 
is still, to a certain extent, an open question. Since the former 
plan involves a severe shock, while the very gradual with- 
drawal seems like the useless prolonging of a battle which 
should be fought in the shortest length of time possible, the 
middle ground seems the safest and best; experience confirms 
the wisdom of rapid lessening of the accustomed dose and com- 
plete withdrawal in from ten to fourteen days. To sustain the 
patient, careful attention must be paid to feeding, and milk or 
meat-broths, with egg-albumen, should be given in suitable 
amounts once in three hours, or even oftener. The excessive 
restlessness is best combated with hot baths. The sleepless- 
ness, if other means fail, may demand the exhibition of such 
hypnotics as sulphonal or hyoscin; in extreme cases even mor- 
phia may have to be given; the objections to the latter course 
are evident. If there is danger of heart failure, stimulants are 
demanded, as alcohol, aromatic spirits of ammonia or digi- 
talis. Much comfort can be afforded if the attendants have 
sufficient devotion to duty and the necessary tact to keep the 
patient's mind busy, drawing his attention from himself to ex- 
traneous matters. 

The specific value of remedies here has not yet been determined. 
Nux vomica, Ignatia, Erythroxylon coca and China sug- 
gest themselves as probably useful; it is stated that China is 
valuable in the diarrhoea which often prevails in these cases. 

The plan, which is occasionally advocated, of first substitut- 
ing cocaine for morphia, and then breaking the cocaine habit, 
does not commend itself to sound judgment. 
43 



674 INTOXICATION, HEAT-EXHAUSTION, OBESITY. 

COCAINISM. 

The cocaine habit is comparatively infrequent, and, when 
found, usually has been acquired with the view of substituting 
it for the morphine habit. Sometimes both exist in the same 
person. 

The symptoms are those of a general breaking-down of body 
and mind. The digestion soon becomes seriously deranged, 
with failure of general health, great emaciation, loss of strength, 
and pasty, 3'ellowish, bronze skin. The pulse is rapid, weak, 
sometimes irregular, and there ma3' be troublesome shortness 
of breath. The nervous S3 T mptoms are restlessness, sleepless- 
ness, instability of purpose, neglect of person, talkativeness, 
untidiness, untruthfulness. Hallucinations and delusions de- 
velop, among which tactile hallucinations, on account of their 
comparative infrequenc3 r , are particular^ noteworthy; the 
patient has a sensation as though something were beneath the 
skin, especially- about the tips of the fingers, and he will pass 
hours in attempting to remove it. Hy^peraesthesia to touch is 
also marked. It is said that a tendenc3^ to malice and ugli- 
ness is common. Unless relieved, the case terminates in insanity- 
with homicidal mania. 

The treatment consists of prompt withdrawal of the drug; 
competent observers consider this perfecth^ safe. The patient 
should be confined in a properh r equipped institution where he 
can be kept under close observation for a considerable period 
of time. Supporting measures must be adopted and especial 
indications met as the3' arise. The general line of treatment is 
much like that of morphinism. 

ARSENICAL POISONING. 

Acute arsenical poisoning causes violent gastro-enteritis, 
often with collapse, and if not fatal, is frequently followed by 
serious nervous affections culminating in paralysis. Treatment 
consists of removal of the poison by emetics and stomach 
pump, the administration of milk and egg and, if the arsenic 
was taken in solution, the use of large doses of dialyzed iron 
(from six to eight drachms). 

Chronic arsenical poisoning; as here discussed, results from 



ARSENICAL POISONING. 675 

long-continued exposure to the action of arsenic contained in 
articles of ornamentation and daily use about the house and 
person, in the manufacture of which compounds of arsenic are 
employed an account of their special merit as brilliant dyes, 
especially reds and greens. To these articles belong fancy 
tissue-papers, artificial flowers, wall-papers and fabrics which 
are used in making carpets, hangings and occasionally wearing- 
apparel. The particular manner in which the poison enters the 
system has been made the subject of careful study. It is 
thought that the arsenic is inhaled in small particles which 
have become detached or in a gaseous volatile form, the latter 
due to the action of a number of moulds, favored by moisture 
and a temperature of from 60° to 95°. The gaseous product is 
an organic derivative of arsenic pentoxide. The question is 
not yet settled, and some go so far as to deny the possibility of 
arsenical poisoning from the sources indicated. 

Symptoms. — The symptoms caused by the accumulation of 
very minute doses of arsenic in the system are exceedingly un- 
certain. There is loss of appetite, nausea, irritation of the 
mucous membrane of the eyes, nostrils, mouth, throat, 
stomach and intestine, dryness of the eyes and nostrils, general 
weakness, emaciation, restlessness and a state of feverish irri- 
tability of the nervous system, with anaemia, sleeplessness, diz- 
ziness, mental depression, fitfulness of disposition, constrictive 
headache, numbness and pricking of the extremities. Very ex- 
ceptionally even more serious disturbances, such as convulsions 
and paralysis, may occur. » 

Kirchgaesser places particular value upon the appearance of 
a brown pigmentation of the skin of the face, inflammatory 
affections of the eyelids, disturbances of sensibility and of mo- 
tion, especially in the lower extremities, with scalding during 
urination. 

The diagnosis usually is difficult, in many cases almost im- 
possible. It is quite probable that only some minor symptoms 
are present which attract attention chiefly by their persistency 
and by the difficulty of accounting for them. In such cases it 
is well to examine into the surroundings of the patient for pos- 
sible causes of chronic poisoning by arsenic; if possible cause is 
found, careful examination of the urine must be made to sub- 
stantiate or disprove the suspicion. 



676 INTOXICATION, HEAT-EXHAUSTION, OBESITY. 

The treatment consists of meeting S3'mptomatic indications 
as they arise. The patient is almost sure to recover if the 
cause of the mischief is found and removed. 



PTOMAINE POISONING. 

Ptomaines and toxines are alkaloids formed in the process of 
decomposition of animal matters, the term "toxines" being ap- 
plied by Brieger to those possessing distinctly poisonous 
properties. This article is restricted to ptomaines taken with 
the food. 

Meat-poisoning- occurs usually from eating sausage, ham, 
head-cheese, meat (pork) pie; less often from eating beef, veal 
or mutton. 

Sausage-poisoning (botulism or allantiasis) is quite common 
in Germany, where the use of meat in this form is extensive. 
Canned meats are not free from danger, and cases of fatal 
poisoning with it are on record, as quite recently the case of 
Mr. Anton Seidel, the distinguished musical leader. 

The symptoms of meat-poisoning are those of acute gastro- 
intestinal irritation; in the case of poisoning by canned meat 
the toxic effects may be due to the formation of muriate of 
zinc and muriate of tin. 

The following description of the Welbbeck cases, furnished by 
Ballard, and quoted by Vaughn, Osier, and other writers on 
this subject, is complete and t\rpical: 

"A period of incubation preceded the illness. In fifty-one 
cases where this could be accurately determined, it was twelve 
hours or less in five cases; between twelve and thirty-six hours 
in thirty-four cases; between thirty-six and forty-eight hours 
in eight cases; and later than this in only four cases. In man}^ 
cases the first definite S}anptoms occurred suddenly, and evi- 
dently unexpectedh T , but in some cases there were observed 
during the incubation more or less feeling of languor and ill- 
health, loss of appetite, nausea, or fugitive, griping pains in the 
belly. In about a third of the cases the first definite symptom 
was a sense of chilliness, usually with rigors or trembling, in 
one case accompanied by dyspnoea; in a few cases it was giddi- 
ness with faintness, sometimes accompanied b}^ a cold sweat 
and tottering; in others the first symptom was headache or 



PTOMAINE POISONING. 677 

pain somewhere in the trunk of the body, e. g., in the chest, 
back, between the shoulders, or in the abdomen, to which part 
the pain, wherever it might have commenced, subsequently ex- 
tended. In one case the first symptom noticed was a difficulty 
in swallowing. In two cases it was intense thirst. But how- 
ever the attack may have commenced, it was usually not long 
before pain in the abdomen, diarrhoea and vomiting came on, 
diarrhoea being of more certain occurrence than vomiting. The 
pain in several cases commenced in the chest or shoulders, and 
extended first to the upper and then to the lower part of the 
abdomen. It was usually very severe indeed, quickly produc- 
ing prostration or faintness, with cold sweats. It was vari- 
ously described as crampy, burning, tearing, etc. The diar- 
rhoeal discharges were in some cases quite unrestrainable, and 
(where a description of them could be obtained) were said 
to have been exceedingly offensive and usually of a dark color. 
Muscular weakness was an early and very remarkable symp- 
tom in nearly all cases, and in many it was so great that the 
patient could only stand by holding on to something. Head- 
ache, sometimes severe, was a common and early symptom; 
and in most cases there was thirst, often intense and most dis- 
tressing. The tongue, when observed, was described as usually 
thickly coated with a brown, velvety fur, but red at the tip and 
edges. In the early stage the skin was often cold to the touch, 
but afterward fever set in, the temperature rising in some cases 
to 101°, 103° and 104° F. In a few severe cases, where the 
skin was actually cold, the patient complained of heat, insisted 
on throwing off the bed clothing, and was very restless. The 
pulse in the height of the illness became quick, counting in some 
cases 100 to 128. The above were the symptoms most fre- 
quently noted. Other symptoms occurred, however, some in a 
few cases, and some only in solitary cases. These I now pro- 
ceed to enumerate. Excessive sweating, cramps in the legs, or 
in both legs and arms, convulsive flexion of the hands or fingers, 
muscular twitchings of the face, shoulders or hands, aching 
pain in the shoulders, joints or extremities, a sense of stiffness 
in the joints, prickling or tingling or numbness of the hands, 
lasting far into convalescence in some cases, a sense of general 
compression of the skin, drowsiness, hallucinations, imperfec- 
tion of vision, and intolerance of light. In three cases (one 



678 INTOXICATION, HEAT-EXHAUSTION, OBESITY. 

that of a medical man) there was observed yellowness of the 
skin, either general or confined to the face and eyes. In one 
case, at a late stage of the disease, there was some pulmonary 
congestion and an attack of what was regarded as gout. In 
the fatal cases death was preceded by collapse like that of 
cholera, coldness of the surface, pinched features, and blueness 
of the fingers and toes and around the sunken eyes. The de- 
bility of convalescence was in nearly all cases protracted to 
several weeks. 

"The mildest cases were characterized usually by little re- 
markable beyond the following S3 r mptoms, viz., abdominal 
pains, vomiting, diarrhoea, thirst, headache, and muscular 
weakness, any one or two of which might be absent." 

Poisoning by milk-products, especially cheese and ice-cream, 
is not uncommon. The symptoms here also are those of vio- 
lent gastro-intestinal irritation. They are caused, according 
to Vaughn, of Michigan, by a substance which he separated 
from poisonous cheese and which he called "tyrotoxicon." 

Poisoning by shell-fish and fish (Ichtysmus) is frequent. It 
is characterized by the same intense action of a toxine upon 
the gastro-intestinal tract which belongs to the other groups. 
Poisoning by mussels, eaten raw or cooked, is the most striking 
form, and was carefully studied in connection -with a series of 
cases which occurred at Wilhelmshaven. It seems probable 
that the mischief arises from the food taken by the mussels or 
from the operation of local conditions; at least the mussels 
transplanted from Wilhelmshaven to other points soon ceased 
to be poisonous, and those introduced from other localities, 
and heretofore perfectly harmless, soon became noxious. The 
same facts, i. e., the effect of food and of local -conditions, may 
be of importance in connection with fish. Breiger separated a 
substance, found chiefly in the liver of the mussel, which he 
called mytilotoxin. The choleraic symptoms from eating 
poisonous mussels are peculiar in that they are accompanied 
with rapid collapse and in some cases death within two or 
three hours. Oysters and various kinds of fish, among them 
the Russian sturgeon, salted, often give rise to serious illness. 

Treatment. — In all cases of ptomaine-poisoning the noxious 
substance must be promptly removed from the stomach. 
Strong black coffee may be administered freely, and other stim- 



HEAT-EXHAUSTION. 679 

ulants may be given, with hot applications to the stomach and 
bowels, and mustard drafts to the feet. 

Arsenicum is of all remedies the most reliable; Veratrum 
album, Camphor and Nux vomica may also be serviceable. 
Bryonia was recommended by Hering. 



HEAT-EXHAUSTION. 



Heat-exhaustion is the result of prolonged exposure to a 
high temperature, especially when combined with severe phys- 
ical exertion. The person is "overcome" by the heat. Expo- 
sure to the sun is not necessary; many cases occur from long- 
continued confinement in a close room during mid-summer, in 
the pursuit of certain employments, as that of stokers on large 
ocean steamers. The mildest form is the great weakness from 
which persons not naturally very strong often suffer during the 
heated term, especially during the hot close nights of mid- 
summer. If severe, this weakness borders upon fainting, with 
pallor and coldness of the surface, sensation of threatening 
heart failure, cold perspiration and great exhaustion. In fully 
developed cases the bodily surface is icy-cold and the pulse 
rapid and feeble; there is restlessness and, possibly, muttering 
delirium, unconsciousness, a rapid fall of temperature to 96° or 
95°, and collapse. 

Diagnosis. — The remarkable fall of temperature distinguishes 
heat exhaustion from thermic fever, which is characterized by 
an equally pronounced rise of the bodily temperature. The 
condition is not always at once distinguished from the collapse 
of heart disease or internal bleeding; however, the history of 
the case and the very markedly subnormal temperature of heat 
exhaustion are usually sufficient to establish the diagnosis. 

Treatment. — While heat-exhaustion is not a condition of 
especial danger, measures for relief should be employed energet- 
ically. The patient should without delay be placed into the 
hot bath and heat be applied in every form. Brisk rubbing is 
excellent. Strychnia and digitalis, hypodermically, will stimu- 
late the heart and the vaso-motor system. Ammonia and 



680 INTOXICATION, HEAT-EXHAUSTION, OBESITY. 

alcoholic stimulants may be given as demanded by the pa- 
tient's condition. After recovery from the attack, perfect rest 
should be maintained for a considerable period of time. 

Thermic Fever, Sun-Stroke. — Thermic fever is an acute fever 
produced by exposure to natural or artificial heat, chiefly by ex- 
posure to the intense heat of the sun while undergoing severe 
physical exertion. Soldiers on the march, heavily encumbered, 
and laborers in the field or on the street furnish many victims. 
Moist heat is much more dangerous than dry heat, hence the 
great frequency of sun-stroke in tropical countries, particularly 
in low, swampy lands and among persons at work in a hot, 
damp atmosphere. It is not unusual, especially in southern 
and moist countries, to have cases of thermic fever occur in the 
night. Men are more liable to the affection than women, on 
account of greater exposure; persons already exhausted by 
fatigue, or weakened by intemperance, beyond doubt furnish a 
large percentage of the victims. Those visiting tropical coun- 
tries and not yet acclimated are in particular danger, while the 
natives may suffer no inconvenience. 

Morbid Anatomy. — H. C. Wood, the highest American au- 
thority on sun-stroke, has shown that mam- of the most strik- 
ing post mortem changes are due to the intense heat of the 
body, modified more or less by- the treatment had and the time 
of death. "If the patient has died during an acute sun-stroke, 
with high temperature, and the autopsy be made at once, the 
left heart will be found contracted, the right heart usually en- 
gorged, the semi-fluid blood collected in the venous trunks, and 
the arterial coats, or it may be the whole body-, marked with 
petechias or stained with decomposing blood. In somecases the 
blood has an acid reaction. Many years ago I proved that the 
cause of the symptoms and the structural lesions in thermic 
fever is simply excessive heat. The history of the development 
of an attack is probably at first a slow rise of the bodily tem- 
perature, produced by the inability- of the system to get rid of 
the heat which is formed in it; after a time the inhibit ory heat 
centers at the base of the brain, which control the formation of 
bodily heat, become exhausted by effort or by the fever itself; 
and as a consequence of the removal of inhibition there is a 
sudden increase of the formation of heat, with a corresponding 
up-bound of the bodily temperature and consequent uncon- 



HEAT-EXHAUSTION. 681 

sciousness from the paralyzing influence of the heat upon the 
cerebral cortex. All the higher tissues of the body are affected 
directly by the excessive temperature, and death from a pure 
heat paralysis of the respiratory centers may quickly occur." 

"Myosin (the substance whose coagulation produces post 
mortem rigidity) coagulates about the maximum temperature 
of sun-stroke. After severe exertion the muscles, including the 
heart, contain an excess of a myosin which is more prone to 
undergo coagulation than is normal myosin. In this fact is 
found the explanation of, the extraordinary positions of the 
corpses of those who have been killed in battle; instantaneous 
death has been followed by an equally instantaneous coagula- 
tion of the myosin of the general muscles, so that the body has 
been frozen in the attitude at which life was stopped. The 
heart is in the center of bodily heat; not rarely in tropical 
battles, especially when troops have been charging up-hill, the 
overstrained heart has been suddenly arrested by the coagula- 
tion of its myosin, and the man has fallen on his face in instan- 
taneous syncopal' death." 

Symptoms. — In a typical and severe case the onset almost 
always is sudden, the patient dropping unconscious, as though 
knocked senseless. If there are prodroma, they consist of 
severe pain in the head, with dizziness, often visual disturb- 
ances, feeling. of great heat and oppression, and sickness at the 
stomach, possibly vomiting. TJnconsciousness may be more or 
less profound; there is usually restlessness, twitching, jerking, 
sometimes convulsions, which may be epileptiform; in other 
cases there is deep coma and complete muscular relaxation; but 
usually the coma develops gradually, it being the rule that at 
first it is possible to partly arouse the patient. With it there is 
dilatation, later contraction, of the pupils. The face is con- 
gested, the eyes blood-shot, the body hot and copiously bathed 
in a profuse hot sweat. The pulse, at first full and bounding, 
becomes rapid, feeble, and compressible. Vomiting and purg- 
ing are present in the greater number of cases; the urine is 
scanty, albuminous, and finally suppressed; breathing becomes 
labored and oppressed. Wood points out that the -whole body 
is apt to exude a peculiar odor, which is especially strong in 
the faecal discharges. The most characteristic symptom is the 
marked elevation of the temperature, which is rarely below 



682 INTOXICATION, HEAT-EXHAUSTION, OBESITY. 

108° in cases sufficiently severe to be marked by unconscious- 
ness, and which may reach 112° or 113°. 

Death may occur in an hour, or less, but more frequently not 
for twenty-four or thirty-six hours; it is due to asphyxia or 
failure of respiration and of the heart. 

Less characteristic is the mild form of sunstroke described in 
India as "ardent continued fever" and observed in the southern 
part of this country. It consists of a continued fever with 
high elevation of the temperature, great prostration, tendency 
to involvement of the nervous system, and a typhoid state. 

The prognosis, in America, is favorable; in India the cases 
are liable to prove fatal from a sudden development of true and 
severe thermic fever. 

It is now thought that many cases of cholera infantum, 
occurring during the extreme heat of summer in the large 
American cities, characterized by cerebral involvement, delirium 
and coma, are in reality cases of thermic fever. 

The diagnosis rests upon the history of the case and the 
remarkable elevation of the temperature. 

The prognosis depends upon the promptness with which 
treatment is begun, chiefly upon the success had in reducing 
the temperature, and upon the effect of this reduction of tem- 
perature upon the nervous symptoms. Recovery may be ex- 
pected if the fever falls and consciousness returns. The recovery 
may not be complete; there may be left permanent^ partial 
loss of memory and impairment of the mental faculties, amount- 
ing to a mild form of insanity; in others there are convulsions 
of an epileptiform type and symptoms of chronic cerebral in- 
flammation. Inability to bear exposure to even moderate heat 
is one of the commonest sequels of thermic fever, and it is 
alwa3 r s advisable to carefully protect persons who have suffered 
from sunstroke against avoidable exposure to heat, even of 
ver}^ hot rooms; abstinence from alcoholic stimulants should 
also be enjoined upon them. 

Treatment. — Prophylaxis consists of such prudential meas- 
ures when exposure to great heat is unavoidable as are within 
the reach of the majority of people; these include moderation 
in the use of stimulants and frequent draughts of cool, not ice- 
cold, water for the purpose of promoting perspiration and of 
keeping the bodily temperature as low as possible; Wood ad- 



HEAT-EXHAUSTION. 683 

vises the addition of claret or some other substance which 
mildly stimulates the gastro-intestinal tract and the skin. 
The habit, common among farmers and teamsters, of wearing 
in the crown of the hat plantain, or other large, leaves and of 
occasionally changing them, is excellent in its way. 

In all. cases of sun-stroke, whether mild or severe, the sick 
person should at once be carried into the shade of a tree or 
house, or placed under the cover of an ambulance, and ener- 
getic measures taken to reduce the temperature. If nothing 
better offers, the larger portion of the clothing may be removed 
and the patient be freely douched with water from the pump or 
hydrant. In cities, where cases of sunstroke occur constantly 
during the heated term, an ambulance will at once be called, 
and the patient removed to the hospital. The value of every 
moment is great, and not an instant should be lost; life itself 
may depend upon promptness of action. 

Quick reduction of temperature is brought about by strip- 
ping the patient and freely and perseveringly rubbing the body 
with large pieces of ice or by putting him at once into a cold 
bath (50° F.), occasionally adding to the water pieces of ice in 
order to maintain a low temperature. A reliable thermometer 
should be kept in the mouth or rectum, and the patient be 
removed from the bath when the instrument registers 101°, F. 
It is, however, a question if in the majority of cases as good 
results would not be obtained by a prolonged bath in simply 
cool, or even slightly tepid, water. While it is not wise to 
ignore the experience of those who in hospital practice claim to 
have demonstrated the necessity of ice and ice-cold baths in 
acute thermic fever, we yet know that in other fevers charac- 
terized by a very high temperature tepid baths promptly and 
permanently reduce it, and that in many cases private practi- 
tioners have found this means thoroughly efficient. Alcoholic 
stimulants may be demanded even while the patient is in the 
bath tub, and hypodermic injections of strychnine or digitalis 
may be indicated by the symptoms. 

The bath may be repeated, but there is much danger of over- 
doing; the temperature and general condition of the patient 
must be carefully considered. 

If there is immediate danger of apoplexy, free venesection is 
advised. Violent convulsions may call for chloroform or hypo- 



684 INTOXICATION, HEAT-EXHAUSTION, OBESITY. 

dermic injection of morphine. Internal medication is of com- 
paratively little use at the time of immediate urgency, although 
drugs which reduce the bodily temperature are to be considered. 
However, after the patient has recovered from the acute attack, 
but suffers from its effects, duty indicated remedies, with the ob- 
servance of quiet, avoidance of further exposure, and a light 
diet, will prove of far greater value than the repeated "local 
bleedings and persistent, merciless counter-irritation, especialty 
by means of the actual cautery" (Wood) which are by some 
authorities considered of so much value when the meninges are 
in a state of chronic inflammation. 

Glonoine is the most important remedy at our disposal. It 
stimulates the vaso-motor centres and the heart. It causes 
symptoms of violent congestion to the head, threatening 
apoplexy, and symptoms of meningeal irritation or inflamma- 
tion. There is great throbbing fulness in the head; congestion 
of the conjunctiva, disturbances or loss of vision; frightful pain 
in the head, which is pulsating and throbbing; he loses knowl- 
edge of his whereabouts, does not recognize familiar objects, as 
his house or the street in which he lives; there is constricted, 
labored breathing; unconsciousness; convulsions. — Veratrum 
viride has a powerful effect in quieting the action of the heart 
and lowering the temperature. Symptoms of cerebral hyper- 
emia and meningeal irritation are prominent, with a tendency 
to convulsive action. In practical usefulness here it ranks next 
to Glonoine. — Belladonna is very useful in the treatment of 
cerebral congestion, with characteristic headache, dizziness, 
etc.; it is serviceable in congestive headaches brought on by 
great heat in the summer, but they are not as intense as the 
headaches which call for Nitro-glycerine. — Opium. Cerebral 
apoplexy, with deep coma, stertorous breathing, cold extremi- 
ties, sometimes much twitching and jerking of muscles, pur- 
plish face, hot sweating. — Gelsemium is of great value when 
blinding headaches with great prostration remain as a sequel 
of sunstroke. It is also important in the milder cases, when 
the patient is conscious of being overcome by the heat. — Amyl 
nitrite resembles Glonoine, but does not in efficiency equal 
the latter during an acute attack. In the cases, however, 
where there remains after recovery from the immediate attack 
very severe pain in the head, with a sensation as though the 



OBESITY. 685 

blood -were surging in great waves to the brain, with difficult 
breathing and oppression throughout the chest, and a sense of 
choking, it is eminently useful. — Ferrtjm phosphoricum is 
helpful when violent headache with symptoms of cerebral con- 
gestion, fiery-red face, great dizziness, and often vomiting, 
result from exposure to the sun. (Lachesis, Stramonium and 
Cimicifuga.) Hale recommends Zincum phos. when there is 
swimming in the head, uncertain gait, difficulty in concentrat- 
ing one's mind, and depression of spirits. 



OBBSITY (Polysarcia). 

A tendency to obesity prevails in certain races and families. 
It usually shows itself after middle life, but is not infrequently 
seen in the young, particularly when over-eating and aversion 
to physical exercise are allowed to be freely indulged. Among 
the immediate causes the most important are over-eating, lack 
of sufficient exercise, and the free use of beer and alcoholic 
liquors. It is, however, a fact that many obese persons are 
not only moderate eaters, but have voluntarily and in vain 
practiced great abstemiousness to circumvent an inherited ten- 
dency to excessive corpulency. 

Aside from the necessary exercise of moderation in eating 
and drinking, obesity need not excite uneasiness unless it is 
sufficient to become burdensome by causing wheezing and 
shortness of breath from moderate exertion or from going up- 
hill, or unless there is interference with the normal functions of 
the heart. 

The treatment of obesity consists of abstinence from alco- 
holic drinks, beer and porter, a properly regulated diet, and 
systematic physical exercise. In providing the latter it must 
call into action all the muscles of the body, should be main- 
tained persistently, and should be increased daily, as the 
strength of the subject allows, inducing free perspiration, but 
stopping short of producing exhaustion. Agreeable exercise 
out-of-doors is to be preferred. It should be followed by a 
bath, brisk rubbing, and rest. 

The diet best suited to the needs of this class of people has 



686 INTOXICATION, HEAT-EXHAUSTION, OBESITY. 

been made the subject of exhaustive study, of which a very- 
complete resume may be found in "Hare's System of Thera- 
peutics." The carbohydrates and fats are no longer considered 
directly responsible for the over-production of fat in the human 
system, but their consumption is still, for evident reasons, al- 
lowed in limited amounts only. 

Of the numerous methods practiced for the cure of obesity, 
those of Banting, Oertel, Schweninger, Ebstein and Yeo are 
best known. Banting reduces the amount of food and liquid 
taken, and excludes fats and carbohydrates. Oertel allows 
only a total of about thirty-six ounces of liquid per day, 
uses a diet composed largely of proteids, employs means to 
produce copious sweating (Turkish bath), and pays especial 
attention to systematic, carefully regulated exercise. His plan 
is particularly applicable to persons suffering from fatty heart. 
Schweninger differs from Oertel chiefly in that he allows no 
liquids at the table nor for two hours after eating. Ebstein 
rapidly excludes all carbohydrates, but recommends the 
free use of fats. Yeo limits the albuminates in the form of 
animal food; reduces to a minimum starchy and farinaceous 
foods, prohibits sugar, allows a moderate amount of fat. He 
forbids drinking with the meal, but recommends the free use of 
hot -water and of aromatic beverages after digestion has been 
completed, between meals. Beer, porter and sweet wine are ex- 
cluded; alcohol can be taken only in very small amounts; hock, 
still Moselle or light claret may be drunk with some alkaline 
table water. Lean meat, game, poultry, eggs and fish (ex- 
cluding salmon, eels and mackerel) are allowed once a day, the 
meat not to exceed six ounces; two eggs, lightly boiled or 
poached, may be taken at one other meal. Bread must be cut 
in thin slices and thoroughly toasted on both sides. Hard 
tack is allowed. Soups as a class must be avoided. A diet of 
skimmed milk may be adopted; otherwise milk is not to be 
used save very sparingly. Farinaceous puddings and pastry 
are forbidden. Fresh vegetables and fruit is allowed. Through- 
out, exercise on foot is necessary. The bowels are to be kept 
open by saline purgatives. 

While many symptoms arising from obesity may come within 
the curative range of the indicated remedy, the condition per 
se is not amenable to treatment by drugs. Attempts to cure 



OBESITY. 687 

obesity by the use of thyroid extract, after the manner recom- 
mended under "myxoedema," have not been universally suc- 
cessful, even though cases have been put on record in which 
good results were claimed. The same may be said of the juice 
of the phytolacca-berry. I have not seen a case in which per- 
manently good results were obtained from the use of "phy- 
toline," so-called. In my own hands, in four patients who 
were exceedingly anxious to find relief, and who took this pre- 
paration for a considerable length of time, the results were 
absolutely negative. I took five ounces of phytoline, observing 
the usual rules of proper diet and exercise, and was forced to 
record an increase in weight of from 224 lbs. to 238 lbs. 



PART VI. 

DISEASES OF THE DIGESTIVE 
ORGANS. 



44 



PART VI 



Diseases of the Digestive Organs. 



DISEASES OF THE MOUTH. 



STOMATITIS. 

(1) Catarrhal Stomatitis (simple, acute, erythematous sto- 
matitis). — The simplest form, frequently seen in young infants 
and children, though by no means limited to them. It is 
usually the result of local irritation, and may be (a) primary 
(from cold, use of irritating drugs, too hot or too cold food, 
lack of cleanliness, abnormal dentition, broken tooth, in adults 
from the too frequent use of tobacco); (b) secondary (from 
gastric or intestinal affection, disease of tonsils or pharynx, 
fevers, etc.). 

The inflammation of the mucous membrane may be circum- 
scribed or diffuse. The mucosa at first is dry, glistening, 
bright-red; later increased secretion takes place, with swelling 
and moderate heat in the mouth. The tongue is swollen and 
coated white; indentations of the teeth are seen on the tongue 
and cheeks. If there is fever, it usually is very moderate; ex- 
ceptionally it is high, and the tongue then becomes dry, red, 
fissured, with dryness and redness throughout the mouth. 
Pain constitutes the most striking symptom. The infant 
frets and worries; it drops the nipple of the breast or bottle as 
soon as it begins to nurse; older children complain of painful 
mastication and deglutition. Copious dribbling of saliva is 



692 DISEASES OF THE DIGESTIVE ORGANS. 

often seen in young subjects. The breath is unpleasantly- 
sweetish, at times sour. Appetite is not much affected. Occa- 
sionally, in severe cases, slight indigestion, diarrhoea, swelling 
of the submaxillar}- glands and, in very nervous children, con- 
vulsions have been noted. 

The average cases recover quickly, usually within a week. 
Relapses are frequent, and are chiefly to be dreaded because 
they interfere with the proper feeding of the child and thus 
tend to weaken it. 

Treatment is prophylactic in so far as proper care of the 
mouth of young infants (washing it with cool water, swab- 
bing it with absorbent cotton) does much toward preventing 
the occurrence of this disease. A child being affected, the cause 
must be ascertained and, if possible, removed. A mouth-wash 
of boric acid (1 to 3 per cent.), bicarbonate of sodium (5 per 
cent.), salicylic acid (0.5 per cent.), or of a weak solution of 
the fluid extract of golden seal is very useful. In chronic 
or very severe cases, the use, after thoroughly cleansing the 
mouth, of a solution of nitrate of silver (2 to 4 grains to the 
ounce) is recommended. 

Consult Belladonna, Aconite, etc. 

(2) Aphthous stomatitis (vesicular or follicular stomatitis, 
canker) may occur at any age, but chiefly in young children up 
to the age of the second dentition. Its characteristic feature 
consists of yellowish, grayish- white patches on the oral mucous 
membrane, chiefly on the lower lip. The affection occurs as the 
result of lack of proper care of the mouth, bad physical habits 
generally, and debility of the system from any cause, such as 
acute diseases like measles, scarlet fever, diarrhoea, pneumonia, 
or wasting diseases, as cancer and tuberculosis ; occasionally 
persons in perfect health suffer from it. 

A small elevation of the mucous membrane, with white centre 
and red margin, in the course of about twenty-four hours 
changes into a creamy patch, which in appearance resembles a 
superficial ulcer surrounded b}- a red margin, rarely larger than 
a split pea, and usually smaller. It heals hy the formation of 
a new layer of epithelium from underneath or from the peri- 
phery, and without leaving a scar. These patches, in excep- 
tionally severe cases, ma}^ become confluent. 

In the majorit}- of cases there is slight, if am-, constitutional 



DISEASES OF THE MOUTH. 693 

disturbance. As in the catarrhal form, restlessness and fretful- 
ness are common in young infants, and difficulty of nursing in 
babies, or painful chewing and swallowing of food in older 
children, must be expected. Increased buccal secretion and 
slight fever are generally present. In the severe cases, com- 
monly of the confluent type, there may be considerable gastro- 
intestinal irritation, probably from extension of the disease, 
with vomiting, diarrhoea and fever. When the stomatitis 
occurs in connection with profound constitutional diseases, as 
the expression of a cachexia, it is secondary, symptomatically, 
to the primary disease, but, interfering with eating and diges- 
tion, may render the prognosis in such cases more serious than 
it otherwise would be. Simple cases readily yield to treatment. 

Treatment. — Cleanliness, especially washing the mouth after 
eating, is important. Mouth- washes are useful, as solutions of 
permanganate of potash (1 per cent.), borax and glycerine, 
chlorate of potash, and astringents generally. In severe cases 
the sore should be touched with nitrate of silver, though cau- 
tion in the use of caustics must be exercised, lest they give rise 
to extensive ulceration. I have found the best results from the 
use of the fluid extract of coptis trifolia (gold thread), from 
forty to sixty drops to the ounce of water; hydrastis also has 
rendered good service. 

Consult: ^Ethusa cynap., Arsenicum, Apis, Arum, Baptisia, 
Borax, Hydrastis, Iodum, Mercurius vivus, Nitric acid. 

(3) Parasitic stomatitis (thrush; mycotic stomatitis) is 
caused by the presence of the saccharomyces albicans (o'idium 
albicans, oi'dium lactis), one of the order of yeast fungi. "It 
develops and spreads in the form of spores between the layers 
of epithelial cells. Mycelial threads now grow outward and, 
especially, inward toward the connective tissue." The tongue 
(dorsum and edge) is most frequently the seat of the affection, 
but it is common on the cheeks, lips and hard palate, and may 
invade the fauces, pharynx and gastro-intestinal mucous mem- 
brane. It has been found in the internal organs (liver, lungs). 
It first appears as slightly raised, pearly- white spots, looking 
like curdled milk, on the mucosa, which rapidly increase in size 
and coalesce. They are easily removed, exposing the underly- 
ing mucous membrane, which may be normal or raw and super- 



694 DISEASES OF THE DIGESTIVE ORGANS. 

ficially ulcerated. Sometimes the entire buccal mucous mem- 
brane is thus covered. 

The disease occurs at am- age, though chiefly among young 
children. It is distinctly contagious, and thus may readily be 
communicated by an infected nipple, as frequently happens in 
large nurseries for young children. The existence of catarrhal, 
or any other form of, stomatitis is an important predisposing 
cause. Improper feeding, lack of cleanliness in the mouth, fer- 
mentation of remnants of food in the mouth and existing 
gastro-intestinal irritation are important etiological factors 
in children. Among adults the affection is oftener seen in con- 
nection with cachectic states, as in the late stages of fevers, 
diabetes, etc. 

The symptoms are those of other forms of stomatitis, arising 
chiefly from the soreness of the mouth. Sometimes the gastro- 
intestinal sjmiptoms are very pronounced, and in rare cases the 
oesophagus is filled with the parasitic mass, making swallow- 
ing practically impossible. 

The diagnosis is easy. The thrush looks like curdled milk, 
but is not as easily removed. In aphthous stomatitis there are 
first vesicles, then patches or ulcers, usually well defined ; more- 
over in thrush the mouth is dry, while in aphthous stomatitis 
there is hypersecretion. Positive diagnosis is made by micro- 
scopic examination for the parasite. 

The prognosis is good, save when the disease appears as the 
expression of a profound cachexia. 

Treatment. — Prophylaxis consists of measures to keep the 
mouth clean and sweet and taking pains, especially when there 
is danger of contagion, to sterilize all media of possible com- 
munication of the fungus. Alkaline mouth-washes and sprays 
are useful in preventing and curing the affection. Thrush hav- 
ing appeared, the fungus should be removed, gently, and the 
parts carefuUV washed with a solution of bicarbonate of soda, 
one drachm to a teacupful of water. Washing, and especially 
spraying, with such solutions as borax (20 grs. to the ounce), 
sulphite of soda (30 to 40 grs. to the ounce), salicjdate of 
sodium (20 grs. to the ounce) is of great service. Borax and 
glycerine, peroxide of hydrogen and permanganate of potash 
are also very useful. It is well to reduce the amount of starch 
and sugar in the food, in order to lessen fermentation and its 
consequences. 



DISEASES OF THE MOUTH. 695 

Reliance, however, is to be chiefly placed upon constitutional 
measures, including every means to improve the general health 
of the patient. The remedies to be consulted are: .^Ethusa, 
Arsenicum, Arum triph., Baptisia, Borax, Hydrastis, Iodine, 
Mercurius yivus, Nitric acid, Carbo vegetabilis, Hepar 
sulph., Kali bichromicum, Kreosotum, Lachesis, Mercur- 
iUs corrosivus, Staphisagria, Sulphur, Sulphuric acid. 

(4) Ulcerative stomatitis (fetid or phlegmonous stomatitis; 
putrid sore mouth) occurs most frequently between the fourth 
and tenth year, very rarely earlier. A specific cause is strongly 
suspected, but has not yet been found. There is evidently a 
local cause at work (bad and neglected teeth, teeth suffering 
from caries or the presence of tartar, catarrhal or other form of 
stomatitis) which acts upon a constitutional predisposition to 
the affection. Improper feeding, general neglect of proper 
rules of living, a constitution enfeebled by some exhausting 
acute disease, or some seated, chronic affection, as syphilis or 
rickets, create this predisposition. Certain drugs, as mercury, 
lead, copper and phosphorus, give rise to a form of ulcerative 
stomatitis. The disease occurs oftener in the damp weather of 
spring and fall. When large bodies of men are exposed to un- 
sanitary influences, as in camps, prisons and similar institu- 
tions, it assumes the form of an epidemic. 

The disease begins at the margins of the gums, usually on one 
side (left), of the lower jaw, eventually extending to the cheeks, 
lips and edges of the tongue. There is great hyperemia of the 
affected mucous membrane, with swelling, redness and bleed- 
ing. Ulceration takes place along the free border of the gums, 
appearing like a narrow, yellowish line, the ulceration rapidly 
broadening and deepening, with necrosis of the bony tissues 
and subsequent dropping out of the teeth. Ulcers may also 
form on the lips and cheeks, at times of considerable size, with 
a soft grayish centre and considerable infiltration of the sur- 
rounding mucous membrane, giving its edge an appearance of 
thickening. 

These local symptoms are accompanied with copious, blood- 
tinged salivation, foul and gangrenous odor from the mouth, 
swollen tongue, fretfulness, sleeplessness, fever of varying de- 
gree, and swelling of the submaxillary glands. In severe cases 
nausea, vomiting and foul diarrhoea may occur. The difficulty 



696 DISEASES OF THE DIGESTIVE ORGANS. 

of taking nourishment is great; hence emaciation and bodily 
weakness are almost alwa} r s present. 

The so-called "mercurial stomatitis" which follows the ad- 
ministration of mercury in some form, not necessarily in large 
doses, presents a clinical picture so closely resembling ulcerative 
stomatitis that it maj be classed under this heading. The 
chief differential feature is an early and pronounced metallic 
taste, more copious salivation, and in exceptionally bad cases 
quite extensive necrosis of the (lower) jaw. It is now a com- 
paratively rare affection, and is best treated with chlorate of 
potash internally and in form of a mouth-wash. 

The diagnosis of ulcerative stomatitis is not difficult. Aphthae 
may resemble its first stage, but, unlike ulcerative stomatitis, 
involves the pharynx and is more superficial. Noma is much 
more destructive and has extensive tumefaction and indura- 
tion of the cheek. It can hardly be mistaken for the ulcers in 
the mouth of nursing women which develop from the mucous 
follicles and, though painful, are easily controlled by the appli- 
cation of nitrate of silver. 

The course of the disease is tedious, particularly so when it 
occurs in connection with rickets or syphilis, or when extensive 
necrosis of the bone has taken place. 

The prognosis under proper treatment is good, although 
recurrences are not unusual. Noma exceptionally occurs as a 
complication, and renders the prognosis serious. 

Treatment. — The necessity of proper care of the mouth and 
of observing the laws of hygiene as prophylactic measures are 
as apparent as that of guarding against infection. The actual 
treatment, strongly indorsed by the best authorities of the 
dominant school, consists of the internal use of chlorate of 
potash, in doses of three grains every three or four hours to a 
child five years old, and of a mouth-wash of 15 to 20 grains of 
the same agent to the ounce. If in exceptional cases this treat- 
ment fails, permanganate of potash (3 grs. to the ounce) or 
nitrate of silver (20 grs. to the ounce) are applied to the sores 
by- means of a brush. Of course, all dead tissues must be re- 
moved. 

Consult: Nitric acid, Mercurius solubilis, Phosphorus, 
Arsenic, Lachesis, Kali bichromicum, Baptisia, Arum. 

Gangrenous Stomatitis (noma,cancrum oris, gangrene of the 



DISEASES OE THE MOUTH. 697 

mouth) primarily affects the gums and inner surface of the 
cheek; it is characterized by tendency to gangrene, with exten- 
sion into, and destruction of, adjacent structures, and a large 
mortality rate. 

It is a rare disease, not confined to any age, but showing a 
decided preference for girls from two to five years old. Cases 
probably occur oftener in damp seasons and countries. 

The existence of great bodily weakness, profound cachexia or 
physical depravity, such as results from severe, and especially 
infectious, disease, in children brought up under unheal thful 
surroundings, almost seems a necessary ^etiological factor. 
Strong, hearty children are practically exempt. It is stated 
that at least one-half of all the cases follow measles; it has 
been known to follow in the wake of scarlet and typhoid fever, 
and may complicate ulcerative and aphthous stomatitis. 

The primary seat of the affection is the mucous membrane of 
one cheek or of the gum; it is rarely seen on both sides. An 
ulcer develops, spreading with startling rapidity in every direc- 
tion, and dipping deep into the tissues, with diffuse swelling of 
the adjacent parts, and showing gangrenous disorganization 
of the affected tissue either from the very beginning or within 
a very short time. The cheek often is perforated, and the de- 
structive process may rapidly involve the face and mouth, 
eating away the cheek, lips, tongue, palate, even the eye and 
ear; attacking the jaw, extensive necrosis may result, with 
loss of teeth and of the bone itself. In mild cases, perforation 
of the cheek, with fistulous ulcer, marks the extent of the 
disease; in the severe and more frequent cases the extensive in- 
volvement described is seen. "The rapidity of the changes 
varies considerably. Perforation may take place in twenty- 
four hours, but oftener after three or four days. It may, how- 
ever, not occur for two weeks. In rare instances I have seen 
the gangrenous process terminate favorably without perfora- 
tion of the cheek" (W. Pepper). 

The local disease is accompanied with severe constitutional 
symptoms. Gangrenous odor from the mouth is present from 
the first. There is usually little pain. Fever, however, of a 
septic character develops soon, and the temperature may reach 
104°. The pulse is rapid and weak. Great depression soon 
sets in, followed by wakefulness and delirium. Diarrhoea is 



698 DISEASES OF THE DIGESTIVE ORGANS. 

present in many cases, but the stomach is rarely disturbed, ap- 
petite being maintained throughout and vomiting rarely af- 
fecting the patient. Diphtheria, aspiration pneumonia, and 
gangrene of the parts (lung, palate, oesophagus, anus, genitals 
or extremities) may complicate the case, death from exhaustion 
or collapse usually taking place within a fortnight. 

The diagnosis presents no difficulty. Anthrax extends from 
without to within. Severe ulcerative stomatitis may lead to 
extensive destruction of tissue, but lacks the characteristic 
gangrenous odor and appearance. 

The prognosis, always grave, depends largely upon the ex- 
tent of the lesion and the presence of complications. If con- 
fined to the gums, the prospect is favorable. It is, however, 
stated that the disease is fatal in at least three-fourths of all 
the cases. 

Treatment. — The treatment is largely surgical, embracing 
the prompt use of powerful caustics for the removal of diseased 
tissue, the protection of sound structures, and the prevention 
of septic matter infecting lungs and stomach or the system at 
large. Antiseptic dressings are imperatively demanded. Pepper 
recommends that the following be smeared freely over the face 
and neck: Rep.: iodoformi, grs. xl; icthyol, gi; lanolin, gij; un- 
guent, petrol., q. s. ad ,$i. M. f. ungt. Close attention is to be 
paid to the diet, which must be concentrated and nourishing. 
Stimulants are well borne and may be used freely. 

Consult: Arsenicum, Mercur. cyanat., Merc, corrosiv., 
Kali chloricum. 

Therapeutics of Stomatitis.— Aconite. Restlessness; fever; 
thirst; dryness and heat of the mouth. In the simple form. — 
^Ethusa cynapium. Aphthae; thrush; dryness of tongue; sen- 
sation of pungent heat in the mouth and throat, with great 
difficulty of swallowing. Indicated chiefly by the presence of 
gastro-intestinal catarrh, with vomiting of curdled milk and 
presence of curdled milk in the stools. — Apis. Diphtheritic 
stomatitis. History of some exanthematous fever. Mucous 
membrane of the mouth bright-red, swollen, and covered with 
small blisters; feels scalded; viscid, tough, frothy saliva; little 
thirst. — Arsenicum. In the serious cases of aphthous, ulcera- 
tive or gangrenous stomatitis. Even in comparatively light 
cases the characteristic symptoms, as burning pain, great 



DISEASES OF THE MOUTH. 699 

weakness, restlessness, etc., are present when Arsenic is indi- 
cated. Provings give, among others, the following: gums 
swollen, bleeding, painful to touch; gums spotted white, cov- 
ered with membrane; aphthous ulceration; burning pain in the 
affected parts; painful blisters in the mouth and on the tongue; 
the tongue swollen, whitish, bluish-red; tongue brown and 
dry; tongue feels scalded and blistered. Bloody saliva. Fetor 
of breath, from ulceration of the gums. It is one of the few 
remedies which may be exhibited with hopes of affording relief 
when sepsis exists or the malignant tendency is pronounced, 
with collapse, anxiety and fear of death, cold and hippocratic 
countenance, ashy in color, with blue rings about the eyes, 
coldness and cold sweat of the face and body, diarrhoea, and 
other evidence of a low state. — Arumtriphyllum. The mucous 
membrane is intensely inflamed ; the entire buccal cavity is 
raw, sore, bleeding ; burning pain in the tongue ; the soreness 
in the mouth is so great he cannot be induced to take food. 
Swelling of (left) submaxillary gland. Itching at the lips and 
nose ; putrid odor. — Baptisia. Physical depravity. Teeth and 
gums dark, purple, swollen, foul, and ooze blood. Foulness of 
breath ; foul ulcers in the mouth, which refuse to heal ; profuse 
salivation ; tongue thick, yellow or brown in the center, with 
red, shining edges ; great weakness, low delirium, foul diar- 
rhoea, typhoid state. Stomatitis occurring from low fevers. 
Mercurial stomatitis.— Belladonna. Of service only in excep- 
tional cases of catarrhal stomatitis, with considerable restless- 
ness and fever. — Borax. One of our best remedies in aphthous 
stomatitis, especially in nursing children, with great heat in 
the mouth and excessive soreness ; the ulcers bleed from slight 
touch and when eating; thirst and vomiting; "dread of down- 
ward motion." — Carbo vegetabilis. Great prostration. The 
gums retracted, spongy, bleed easily; tendency to collapse, 
with cold tongue, offensive odor from the mouth ; brown, yel- 
low, vSlimy diarrhoea. — Hepar sulph. White aphthous pus- 
tules on the inside of lips, cheeks and tongue, "with pain, -worse 
from touch and drinking ; ulcerations with lardaceous base. 
Sour, metallic taste; sticking pain.— Helleborus niger. 
Mouth full of flat yellow ulcers, with elevated gray edges or 
red, swollen base. Carrion-like odor : salivation ; glands under 
the jaw and on the neck swollen. — Hydrastis. Aphthae in chil- 



700 DISEASES OF THE DIGESTIVE ORGANS. 

dren ; great dryness of the tongue, with feeling as though it 
had been burnt ; tongue dark-red, with raised papilla? ; peppery 
taste in the mouth, sticky sensation in the mouth ; presence in 
the mouth of sticky, rop}^ saliva which can be drawn out in 
long shreds. Mercurial stomatitis. — Iodum. Small, ash- 
colored, painful ulcerations on the gums ; gums red and 
swollen, receding, bleed easily ; profuse, fetid ptyalism ; offen- 
sive nasal catarrh ; glandular swellings ; patient thin, 
scrawny. — Kali bichromicum. Fat, sluggish children. Gums 
livid, sensitive, ulcerated. Tongue coated 3^ellow or yellowish 
white. Burning, stinging pain in the tongue. Ulceration of the 
soft tissues, eating deeply ; profuse pt} r alism ; stringy mucus in 
the mouth ; languor. Said to be useful in syphilitic ulceration 
in the mouth. — Kali chloricum. Gangrenous ulceration in 
the mouth. The mucous membrane is red and swollen ; ulcera- 
tion in lips and cheeks, with gray base. Profuse flow of acid 
saliva. Throat red and oedematous; submaxillary glands 
swollen. "It has been found extremely useful in gangrene of 
the mouth, nearly every case having been cured at the Five 
Points Hospital, New York, where it was used internally and 
locally." (T. F. Allen) — Kreosotum. In the lighter cases with 
a spongy, scorbutic condition of the gums, constant oozing of 
blood from the gums, putrid odor from the mouth, hard swell- 
ing of the glands, and decay of the teeth. — Lachesis. Gums 
bleeding, swollen, spongy, dark, bluish-red, painful. Aphthae. 
Bluish ulcers, sensitive to touch, with ichorous, offensive dis- 
charge. Tongue red, dry, blistered, or tip red and center 
brown; or red strip in the center. Copious flow of saliva. 
Great fetor from the mouth. Dark, offensive stool. Urine 
smells strong. General weakness and tremulousness. Gangre- 
nous tendency. T^-phoid state. — Mercurius. Gums unhealthy, 
spongy, pale, receding, bleeding. Unhealthy, fetid odor from 
the mouth. Ulcers and pustules in the mouth, on the gums. 
Tongue swollen, flabby, bearing upon it the imprint of the 
teeth. Copious and bloody salivation. The ulcers spread 
rapidly and superficially. Sharp sticking pains in the throat 
upon swallowing. Teeth loose, inflamed, sore. (Merc, solub. 
in light cases ; Merc, cyanat. and Mercur. corrosiv. adapted 
to cases where there is intense action, tending to destruction 
of tissue, as in gangrenous stomatitis.) — Nitric acid. Gums 



DISEASES OF THE TONGUE. 701 

white, swollen, bleeding ; blisters and vesicles on the lips ; sores 
on the inner cheek ; yellow ulcers, with pricking pain as from 
a splinter ; teeth loose ; fetor ; profuse ptyalism. The saliva is 
fetid, acid, and irritating ; it causes sores where it touches the 
lips or chin. — Phosphorus. Clinically of especial value when 
the bone is affected. — Staphisagria. "Aphtha?. Blisters chang- 
ing into cancer sores, with bluish-red or yellowish base. Gums 
pale, white, ulcerated ; painful excrescences on the gums and 
in the mouth, which bleed easily. Mouth and tongue blistered 
and ulcerated." Cervical glands swollen. Teeth crumble to 
pieces. Child looks sickly; pale face, with dark rings about 
the eyes ; peevishness; violent temper. — Sulphur. Frequently 
useful as an intercurrent in tedious cases when there is evi- 
dence of psora. — Sulphuric acid. "Aphtha? occurring during 
protracted diseases, especially in children with marasmus, 
with salivation, sour vomiting, stools like chopped eggs." T. 
F. Allen. — Great weakness and exhaustion. Gums yellowish- 
white. 



DISEASES OF THE TONGUE. 

The morbid conditions of the tongue which are of practical 
interest to the physician are: paralysis, inflammation, simple 
ulceration and malignant ulceration or cancer of the tongue. 
Of these, paralysis has been discussed in another section; cancer 
of the tongue belongs to the field of surgery. 

GLOSSITIS. 

Glossitis or inflammation of the tongue may be superficial or 
parenchymatous, and in either form acute or chronic. 

Superficial inflammation is the result of trauma (broken 
teeth, the action of some local irritant, as corrosive substances) 
or is seen in connection with some disease of the mouth, 
pharynx or tonsils, or in fevers or gastric affections. The 
parenchyma may become involved from a primary superficial 
glossitis, in persons with a predisposition to involvement of 
deep structures, causes which other-wise would give rise to 
superficial inflammation at once affecting the substance of the 



702 DISEASES OF THE DIGESTIVE ORGANS. 

tongue; or it may follow such diseases as erysipelas, tuber- 
culosis, S3 r philis, scurvy, gout, rheumatism. In the past, the 
use of mercury in large doses was a prolific cause. Occasion- 
ally, epidemics of glossitis have occurred. 

The symptoms in cases which involve the superficial tissues 
only are insignificant; there is often a sense of burning soreness 
and some pain upon eating. Acute inflammation of the paren- 
chyma of the tongue is characterized by severe pain and im- 
mense swelling of the tongue, often beginning at the root and 
developing with startling rapidity. Within a few hours the 
tongue will completely fill the mouth, protrude from the lips, 
depressing the jaw, rendering swallowing almost, and often 
quite, impossible, even threatening suffocation from pressure 
upon the epiglottis and soft palate. The tongue itself is dry, 
hard, immovable, exceedingly painful. There is swelling of the 
submaxillary and cervical glands, increased salivary flow, fetor 
of breath and fever. 

The course of the disease is rapid. Resolution ma} 7 take place 
in a few days; or the acuteness of the inflammation may sub- 
side, the swelling decrease, and a chronic hypertrophy remain. 
Or an abscess may form, the evacuation of which will give im- 
mediate and great relief. In other cases gangrene may occur 
as a dangerous complication; or death may result, usually 
from suffocation. — Chronic parenchymatous glossitis is char- 
acterized by a moderate enlargement of the entire tongue or of 
parts of it; there is slight pain and some difficult} 7 of speaking 
and swallowing, depending upon the degree of enlargement. 

The diagnosis is easily made. The intensity of the local symp- 
toms and the rapid course of the affection are decisive. 

The prognosis is unconditionally favorable in the acute super- 
ficial form; it must be guarded, so far as rapid and permanent 
cure is concerned, in the chronic superficial form, since recur- 
rences from slight provocation, as some gastro-intestinal dis- 
order, are exceedingly common. 

Acute parenclrymatous glossitis must be considered a serious 
affection, with probably favorable termination if properly 
treated, but involving the possibility of death from suffoca- 
tion. The formation of an abscess, though not without danger 
and increasing the duration of the attack, has a favorable effect 
upon the termination. If glossitis occurs as an expression of 
sepsis, the prognosis is grave. 



DISEASES OF THE TONGUE. 703 

Treatment. — In the superficial forms early demulcent washes 
(as slippery elm) and astringents (as tincture of myrrh) may be 
used. Bits of ice may be kept 'in the mouth, as both comfort- 
ing and helpful. In the parenchymatous form more energetic 
measures must be employed, including free leeching under the 
jaw and deep scarification of the tongue. The tongue must be 
kept moist, by sprays (borax, bicarbonate of sodium) and 
washed freely for the removal of secretions and epithelium. 
The formation of an abscess can usually be detected by the 
appearance of a circumscribed, well-defined swelling ; it must 
be opened freely. It may be necessary to administer food by 
enema or nasal tube. 

Therapeutics.— Aconite. High fever; dry, hot skin; quick, 
sharp pulse ; intense, agonizing restlessness, headache, possibly 
delirium ; piercing, tingling, sticking pain in the tongue. — Apis. 
Tongue red, puffed, swollen; stinging pain in the tongue; 
blisters on edge and dorsum. — Arsenicum. Burning, like fire, 
in the tongue; gangrenous and malignant tendency. — Bella- 
donna. Tongue hot, dry, painful to touch ; feeling on the tip 
as though it were blistered, with burning pain, especially when 
touched. Papillae dark-red, swollen edges and tip pale red. 
Violent congestion. — Cantharides. Tongue fiery red, blistered, 
excoriated; burning pain in the mouth and throat; burning, 
smarting vesicles in the mouth. — Lachesis. TongUe blistered 
and ulcerated, especially on the tip ; tongue dry, red, black, 
stiff; tongue cracked, mapped ; gangrene. — Mercurius. Hard 
swelling of the tongue, with ulcerations on the edge ; indenta- 
tions on the tongue from .the teeth; severe pricking, burning 
pain in the tongue ; salivation ; foul breath. 

For the chronic form consult also: Conium, Cuprum, Benzoic 
acid, Calcarea carbonica, Carbo animalis, Lycopodium, 
Silica. If the disease results from the abuse of mercury: 
Nitric acid, Hepar sulphur., Kali chlor. 

For Cancer of the Tongue study: Arsenicum alb., Arseni- 
cum iodat., Hydrastis, Lachesis, Nitric acid, Carbo vege- 
tabilis. 

SIMPLE ULCERATION OF THE TONGUE. 

Practically a "molecular necrosis," caused by traumatism 
(from broken teeth, tartar on the teeth, prick by some sharp 



704 DISEASES OF THE DIGESTIVE ORGANS. 

instrument) or the result of indigestion from errors in diet, 
dyspepsia, etc. The ulcer is usually seen on the frasnum of the 
tongue, often on the tip, less frequently on the dorsum. It is 
flat, usually superficial, covered by a dirty j^ellowish slough 
and surrounded by a limited area of inflammation. There is 
much tenderness to touch, at times considerable burning pain, 
more or less offensive odor from the mouth, and in some in- 
stances enlargement of, especially the sublingual, glands. When 
depending entirely upon gastric derangements, the nature of 
the ulceration is evident from the constitutional symptoms 
present. 

Treatment. — The so-called dyspeptic ulcer will heal when the 
gastric symptoms have been removed by appropriate treat- 
ment. Attention to the mouth, as to perfect cleanliness, and 
the use of cooling mouth-washes is necessary. Hydrastis, 
properly diluted, makes an excellent local application. In 
severe cases the use of nitrate of silver, directly applied to the 
ulcer, is highl}' beneficial. The remedies oftenest indicated are : 
Arsenic, Hydrastis and Mercury. Consult also Baptisia, 
Borax, Graphites, Natrum muriat., Sulphur, Kali bichro- 
micum, Nitric acid, Lycopodium, Phytolacca. 



DISEASES OF THE SALIVARY GLANDS. 

Ptyalism or hypersecretion and Xerostomia or arrest of the 
secretion constitute the functional disorders of the salivary 
glands. The former is seen in acute fevers (small-pox), occurs 
occasionally in connection with certain derangements of the ner- 
vous system, sometimes during pregnane}^ or menstruation, and 
as the result of the use of mercury, iodine, gold, copper, jabor- 
andi, and other drugs. Xerostomia (dry mouth) is infrequent, 
of unknown origin, and consists of an arrest of the secretions 
of the buccal and salivary glands, giving rise to excessive dry- 
ness of the entire mouth and tongue, which renders speaking 
and eating very difficult. Osier reports a case which 3-ielded to 
treatment by galvanism. t 

Inflammation of the salivary glands is usually of a specific 
character, and has been discussed. A non-specific inflamma- 



DISEASES OF THE PHARYNX. 70S 

tion sometimes occurs during the course of infectious fevers, 
especially typhoid, as the result of extension of inflammatory 
action along the salivary duct to the salivary gland. Its ten- 
dency is to rapid suppuration and its appearance is an unfav- 
orable symptom. Paget has called attention to a form of par- 
otitis which is seen in connection with diseases or injuries of 
the abdomen or pelvis, and Gowers speaks of its occurrence in 
association with facial paralysis. 

Ptyalism as a symptom is treated by the constitutional 
remedy "which covers the totality of symptoms. Non-specific 
inflammation, in addition to the indicated remedy, may require 
leeching or the use of hot fomentations, and early incision if 
suppuration becomes established. 



DISEASES OF THE PHARYNX. 

ACUTE CATARRHAL PHARYNGITIS. 

Sore throat or simple angina is an inflammation of the 
pharyngeal mucous membrane and the underlying structures, 
and usually involves the uvula, fauces and palate. The chief 
causes are taking cold, especially from exposure to a draught, 
sudden chilling, and wet feet. It may arise from local irritation. 
It affects children oftener than adults, and women oftener than 
men. It prevails chiefly in spring and autumn. 

The premonitory symptoms are shivering and indisposition, 
with headache, slight fever and aching of the bones, neck and 
back; at times the attack is ushered in by a chill. Swelling and 
soreness of the throat then occurs, with sharp, stitching pain, 
most pronounced when attempting to swallow, the pain fre- 
quently shooting into the ear. The voice is thick, the throat 
filled with tough, stringy mucus, and there may be dulness of 
hearing. Hoarseness and hacking cough are often present, 
especially when there is laryngeal involvement. Examination 
of the throat at first shows a dry, glistening, congested mucous 
membrane, in places covered with grayish mucus ; later, the 
pharyngeal mucosa is thickened, somewhat roughened, and 
here and there covered with a sticky, brownish secretion. The 
45 



706 DISEASES OF THE DIGESTIVE ORGANS. 

uvula, fauces and palate are congested and inflamed, and the 
tonsils often covered with a white deposit which is easily 
removed and leaves the underlying surface intact. Recovery 
usually takes place in a few days, the glandular swelling, ten- 
derness and pain disappearing gradually or the sjmiptoms 
ceasing suddenly. 

The duration of the attack is from two or three days to a 
week, or longer. The pharynx may remain sensitive, in which 
case slight exposure will precipitate a recurrence of the affec- 
tion, with a tendency to chronic pharyngitis. 

Treatment. — The general treatment is simple. It consists of 
the use of soft, bland food — liquid if most agreeable to the 
patient — and the exhibition of the indicated remedy. Oil- 
sprays are soothing ; Ivins recommends some fluid petroleum 
preparation. Tannic acid (fifteen grains to the ounce of albo- 
line or glycerine) as a spray is excellent when there is much 
oedema. Gargling is practically useless in the case of children. 

Aconite, Belladonna, Ferrum phosphoricum, Guaiacum, 
Mercur. iodat. rub. and Merc, iodat. flaw are oftenest indi- 
cated; but consult also: Ammon. mur., Apis, Kali bichrom., 
Kali muriat., Lachesis, Phytolacca, Sanguinaria, Capsi- 
cum, Lycopodium, Cantharides, Rhus toxicodendron. 

CHRONIC CATARRHAL PHARYNGITIS. 

This form of sore throat is characterized " by congestion and 
relaxation of the mucous membrane of the pharynx, palate and 
uvula ; there is no marked involvement of the follicles, and the 
morbid process never terminates in ulceration." It prevails in 
moist climates and in places where sudden changes in weather 
are frequent, and finds its victims among all classes. Any condi- 
tion which weakens the pharynx becomes a predisposing cause, 
such as repeated attacks of acute catarrhal sore throat or the 
excessive use of alcohol or tobacco. It is also seen in connec- 
tion with disorders of digestion and uterine irritation. A 
chronic attack may assume acuteness from a comparatively 
trifling cause. 

Hypertrophy of the mucous membrane and of the submucous 
tissues, with enlargement of the glandular structure and hyper- 
secretion, the parts later presenting an irregular roughness, 






CHRONIC CATARRHAL PHARYNGITIS. 707 

with scattered patches of atrophied tissue, constitute the char- 
acteristic anatomical changes. 

The symptoms consist chiefly of dryness, fulness and burning 
soreness of the throat. In the morning the patient awakens 
conscious of the presence of mucus in the throat, of which he 
relieves himself by more or less violent hawking and coughing ; 
this mucus is tough, stringy, thick or thin, sometimes lumpy, 
and in appearance varied, at times grayish- white, again yellow- 
ish, greenish, or bloody. During the day the throat is cleared 
mechanically or the secretion swallowed with the saliva. The 
throat feels rough and dry, especially in the evening, and there 
is occasionally moderate soreness upon swallowing. The voice 
is slightly rough, husky and under imperfect control ; long-con- 
tinued speaking or singing readily brings out this fact. Sudden 
dropping of the secretion into the larynx is common and very 
annoying. Elongation of the uvula is frequently present, and 
may provoke much coughing, sometimes in violent paroxysms. 
Chronic laryngitis is a common complication, and becomes the 
cause of much additional inconvenience and suffering. Un- 
pleasant taste in the mouth and fetor from the mouth are often 
observed. The general health is not affected. 

The prognosis must be guarded as to duration and results of 
treatment. Some cases yield promptly, while others defy every 
recourse of the physician. The latter is especially true in 
scrofulous patients or in those of habitually low vitality. 

Treatment. — Thorough cleansing of the affected parts and 
the persistent use of the indicated remedy, with such measures 
as promise to improve the general health and to lessen the sus- 
ceptibility of the patient to take cold, constitute the treatment 
of chronic catarrh. The latter will be accomplished by order- 
ing an out-of-door life, equally free from unnecessary exposure 
and from constant "fussing." The use of " wraps " about the 
neck should be forbidden ; if necessary, much patience must be 
used to gradually accustom the patient to get along without 
such unnecessary protection. Bathing the throat and upper 
chest daily at first in tepid, then in cool, and finally in cold, 
water is to be regularly practiced, the bath to be followed by 
the brisk use of the Turkish towel. The feet must be kept dry 
and warm. Cleansing of the parts may be accomplished with 
the spray or cotton carrier. The following topical applications 



708 DISEASES OF THE DIGESTIVE ORGANS. 

are recommended by Ivins: Aqueous hydrastis (crude), kali 
bichrom. or kali permangan. (1 per cent, solution), soda bi- 
carbon. (5 per cent, solution), eucalyptus (10 per cent.). If 
these fail, tannic acid, 10 grs.; chloride of zinc, 5 grs.; iodine, 
10 grs.; glycerine, one ounce, may be occasionally used. 

Consult Alumina, Calc. phosphor., Hydrastis, Kali 
bichrom., Mercury, Nux vom., Pulsatilla, Wyethia. Also: 
^Esculus, Argent, nitric, Cepa, Elaps, Kali iodat., Kali 
muriat., Magnesia phosphor., Natrum muriat., Iodum, 
Sulphur. 

FOULICULAIt PHARYNGITIS. 

The essential point, anatomically, is the involvement of the 
follicles, which become distended, singly or in little groups or 
chains, each follicle surrounded l:>3 r a narrow band of inflamed 
tissue, with engorgement of communicating vessels and exuda- 
tion from the follicle. The process may be acute or chronic. 

In the acute form the contents of the follicles are expelled 
within a few days, the thickly dotted exudations, upon super- 
ficial inspection, bearing the appearance of a membranous de- 
posit. The follicle usually returns to its normal state when 
emptied of its contents ; ulceration may result when the parts, 
from cachexia, weakness or vicious habits, are lacking in re- 
cuperative power. The constitutional S3*mptoms are those of 
acute catarrhal pharyngitis, with rather more severe burning 
dryness in the throat and more pronounced splinter-like pain; 
the expectoration also differs somewhat in that it usually is 
heavier and thicker. 

Examination of the throat establishes the diagnosis ; in light 
cases the smallness of the inflamed follicles may cause them to 
be overlooked ; hence the need of care. Recovery usually takes 
place in a few da} r s; if it is incomplete, the foundation may be 
laid for the chronic form of the affection. 

Treatment consists of internal medication and of such local 
measures as will relieve the pain and dryness in the throat. 
Spraying with alboline or liquid vaseline affords much relief; 
lrydrastis and eucalyptus, properly diluted, may be used in the 
same manner. 

Chronic follicular phar^mgitis or Clergymen 's Sore Throat 



FOLLICULAR PHARYNGITIS. 709 

occurs oftener in men than in women, and attacks especially 
persons in the early prime of life who are overworked in seden- 
tary occupations and whose vitality is low. The previous oc- 
currence of repeated attacks of acute catarrhal or follicular 
sore throat, particularly in those of a strumous diathesis, con- 
stitutes a powerful predisposing cause. Overexertion of the 
voice, exposure to cold and irritation of the weakened mucous 
membrane by mechanical and chemical emanations from vari- 
ous manufacturing processes are common direct exciting 
causes. 

In the early stage there is congestion of the mucous mem- 
brane and enlargement of the follicles, varying in size from a 
millet-seed to a small pea, occurring singly, in groups, or form- 
ing a chain. The follicles are transparent or opaque, sur- 
rounded by a narrow band of inflamed mucous membrane, 
which may extend and eventually assume a dry, glistening ap- 
pearance. The throat looks rough and raw, but removal of 
the viscid secretion shows the mucous membrane intact. The 
follicles continue to enlarge, coalescing and forming "broad 
flattened elevations or long ridges," velvety in appearance and 
elastic to the touch, extending in various directions and 
usually surrounded by a network of injected superficial veins. 
The exudation from them is viscid, hanging in slight threads 
from the follicles, or covering the parts like a membranous 
patch; sometimes this exudation appears "cheesy," and in ex- 
ceptional cases it is chalky or calcareous. When the vault of 
the pharynx is involved crusts of hardened secretion are seen 
on the pharyngeal wall behind the soft palate. 

Suppuration and ulceration of the follicles may take place on 
any of the mucous surfaces, especially in cachectic, tuberculous 
or syphilitic subjects ; the erosions which exceptionally result 
may be followed by more or less bleeding. Alarming, and even 
fatal, haemorrhages have been observed in rare cases. 

The subjective symptoms in the early stage are not at all 
severe, consisting chiefly of dryness in the throat, with a sensa- 
tion of moderate stiffness. Later, symptoms of laryngeal 
origin show themselves, chiefly hoarseness and cough, with 
soreness and tenderness in the larynx and arch of the palate. 
These increase, and the feeling of dryness, now often accompa- 
nied by pricking pain, becomes constant and very annoying. 



710 DISEASES OF THE DIGESTIVE ORGANS. 

Speaking grows difficult, and the voice is muffled, hoarse 
and uncertain, its pitch often changing suddenly and in the 
most unexpected manner ; a drink of water relieves. This 
symptom is especially noticeable in public speakers, and has 
given rise to the term " clergymen's sore throat," a misnomer, 
since public speakers constitute but a small proportion of the 
victims of this affection. Swallowing becomes painful, breath- 
ing often labored, and deafness, more or less complete, may 
result and even prove permanent. The senses of taste and 
smell are blunted. Throughout, hawking and violent clearing 
of the throat remain prominent symptoms ; in exceptional 
cases with severe laryngeal complications, cough is so marked 
a feature that tubercular trouble may be suspected. 

General health, in the great majority of cases, is not impaired. 
Occasionally extensive destruction of the glands and of the 
adjacent tissues takes place, producing a dry, glistening ap- 
pearance of the mucous surface — the so-called pharyngitis sicca. 

The diagnosis presents no difficulty, but since the affection 
not infrequently is associated with tubercular disease, the 
specific micro-organism of tuberculosis may be detected. 

The prognosis is favorable, but the disease is very un3 r ielding 
and chronic. 

Treatment. — The various general measures already mentioned 
under catarrhal pharyngitis must be carried out here, and 
everything done to " strengthen the throat." Cauterization or 
rough treatment of the parts by caustics is risky and should 
be discountenanced. Local applications are useful ; the iodide 
of glycerine is especially soothing. Ivins recommends as a 
gargle : glycerine, 1 teaspoonful ; alcohol, % teaspoonful ; 
water, 4 teaspoonfuls. Hydrastis, Sanguinaria, Phytolacca, 
Argentum nitric, properly diluted, may be used to advantage. 

Moderation and wisdom in the use of the voice are very 
essential. Public speakers and singers who suffer severely had 
best give the vocal organs absolute rest, so far as public work 
is concerned, until the disease is well under control ; but it is 
not advisable to wholly desist from the use of the voice in 
common speaking or singing. When possible to do so, the 
advice of an experienced teacher of voice-culture may be utilized 
to great advantage in determining the proper care and use of 
the vocal organs. 



FOLLICULAR PHARYNGITIS. 711 

The most important remedies are : Argent, nitric, Arsenic, 
iodat., Kali bichrom., Mercur. protoiodat., Wyethia, San- 
guinaria. The following are often useful : Alumina, ^Esculus, 
Argent, met., Ammon. bromat., Calcarea phosph., Arum, 
Hepar sulph., Kali muriat., Lachesis, Merc, biniodat., 
Natrum muriat., Nux yom., Phosphorus, Phytolacca, 
Plumbum, Rhus toxicodendron. 

Therapeutics of Catarrhal and Follicular Pharyngitis. — 
Aconite. Early stage of an acute attack. Characteristic 
restlessness, thirst, etc. Parts dark-red. Constrictive dryness 
and stitching pain in the throat. During dry, cold, windy 
weather.— ^Esculus hippocastanum. Catarrh of the gastro- 
mtestinal mucous membrane, with tendency to constipation 
and haemorrhoids. Pharynx and fauces relaxed, puffed, dark- 
red. Great dryness, burning and scraping in the throat and 
posterior nares. Sensation in the parts as though they were 
excoriated, with pricking. Hawking of clear mucus; "drop- 
pings" into the throat. — Alumina. Dryness of throat and 
huskiness of voice, worse in the morning on first waking. 
Throat dark-red, relaxed, the follicles inflamed. Uvula 
elongated and dark -red. Nasal catarrh. Dropping of mucus 
into the throat. Sensation of fulness in the Eustachian tubes, 
with "snapping" in them when swallowing. Hawking of thick, 
tough mucus. Accumulation of thick, tough mucus in the 
throat. Pharyngitis sicca. Relief from warm drinks and 
warm food. — Ammon. brom. Pharynx mottled ; .fauces dark- 
red and congested. Chronic cough, with scanty, stringy expec- 
toration. Follicular form.— Ammon. muriat. Acute catarrhal 
form. Rawness of the pharynx and naso-pharynx. Hard 
cough, with difficult expectoration of tough, stringy mucus. 
Burning in the larynx and hoarseness.— Apis. Acute catarrhal 
form. (Edematous, bright-red swelling of all the soft parts of 
the throat, with feeling of constriction, stinging pain, some- 
what difficult breathing and swallowing, fever without thirst, 
and relief from cold.— Argentum met. Condition chronic. As 
soon as he begins to talk or sing, easy expectoration of mucus, 
which looks like boiled starch. Hoarseness.— Argentum nitric. 
Chronic sore throat (follicular). The parts look dark-red. 
Pain as from a splinter lodged in the throat whenever the parts 
are used. Dryness when beginning to speak. Slight hoarse- 



712 DISEASES OF THE DIGESTIVE ORGANS. 

ness. Burning and scraping in the throat. Hawking of thick, 
tenacious mucus.— Arsenicum iodat. One of our best remedies 

it onic follicular sore throat occurring in phthisical patients. 

There is much burning rawness and soreness in the throat, with 

ant scraping and hawking. Its exhibition is demanded 

is iaitional rather than local symptoms.— Arum tri- 

m, Especially adapted to cases in which hoarseness and 

uncertainty of voice are marked, either continuously, or from 

overexertion, or from cold. The modulations and pitch of the 

voice are practically beyond control, and are constantly and 

unexpectedly changing; hence a great remedy for operatic 

singers and public speakers. In the more aggravated cases the 

I objective symptoms are well pronounced. There is oedema, 
violent burning soreness in the mouth and throat, with great 
aggravation from attempts to swallow ; ulceration in the 
mouth; foulness of breath ; profuse secretion, with constant 
hawking and spitting. — Belladonna. In acute cases only, 
with much and bright redness; great dryness and heat, as 
though scalded ; painful swallowing, especially empty ; shoot- 
ing pains in the throat ; sense of constriction or contraction ; 
small ulcerations in the buccal cavity, especially on the tonsils ; 
all use of the throat is painful.— Calcarea phosphorica. 
"Sensation of dryness and burning in the naso-pharynx during 
empty wallowing or when swallowing first mouthful of food 
or fluid, not after; fulness in naso-pharynx, either imaginary 
or due to the presence of mucus mixed with blood ; pure, partly 
coagulated blood; or yellowish-white, thick discharge." 
" hen swallowing saliva, feels as though the uvula had been 
swallowed and had adhered to the posterior wall of the 
pharynx, where it would choke him ; only relieved by a repeti- 
tion of deglutition (Ivins)." Said by R. T. Cooper to be almost 
a specific for adenoid vegetations.— Cantharides. Intense 
constriction and pain at the posterior aspect of the throat. 
Ti oat feels on fire; pain intense, rendering swallowing, espe- 
cially liquids, almost impossible. — Capsicum. "Sore throat 
complicated with rheumatic and gastric ailments, especially of 
spirit drinkers and smokers, with morbid retching, relaxed 
uvula, dryness and smarting in the throat." Dark redness of 
the throat, with burning, pungent sensation in the pharynx, 
elongated uvula, causing tickling and dry hacking cough, with 



FOLLICULAR PHARYNGITIS. 713 

free expectoration of mucus from the trachea.— Cepa. Sore- 
ness, dryness, sensation of cold in the throat ; coryza with bland 
lachrymation and watery, acrid nasal discharge ; cough from 
tickling in the larynx.— Elaps. "Posterior walls of the pharynx 
covered with crusts or the mucous membrane fissured. Con- 
gestive, lancinating, frontal and occipital headache, aggravated 
by motion and stooping. Complicated with nasal and aural 
catarrh, especially in children (Houghton)."— Ferrum phos- 
phor. Acute attacks, with considerable fever. The parts are 
inflamed, dry, red, hot. Red face. Painful swallowing. — 
Guaiacum. Constantly used in the practice of the dominant 
school in the acute form, especially of rheumatic origin. Its 
use, so far, is empirical ; its action resembles that of Aconite. 
It is probable that pricking pain in the posterior throat, very 
great dryness in the mouth, copious flow of saliva and laryn- 
geal inflammation will prove reliable indications. — Hepar sul- 
phur. Throat dry and raw ; pain as from a splinter or fish- 
bone sticking into the throat ; sticking pain running into the 
ear when swallowing. Tickling, harassing cough, dry or with 
raising of mucus. Chronic venous congestion of the mucous 
membrane of pharynx and larynx. — Hydrastis. Of especial 
value when the posterior nares are involved, with sticky, tena- 
cious whitish or yellow mucus hanging from the naso-pharynx, 
with, often, much rawness of the parts. Or dry, glazed, some- 
times fissured, condition of the mucous membrane, "with expul- 
sion of tough greenish mucus. Elevations on the mucous mem- 
brane. Ulcerations.— Iodum. Swelling and elongation of uvula; 
scraping and burning in the throat, extending into the oesopha- 
gus ; ulceration in the throat, with swelling of the cervical 
glands. — Kali bichromicum. Pharynx glossy, dull-red, cop- 
pery ; pharynx dry, irritable ; the arches of the palate especially 
are involved; hard cough, kept up for a long time, with expec- 
toration of tough, stringy, sticky mucus which is dislodged 
after much difficulty ; when coughing, solid little lumps of 
mucus are suddenly and with much force expelled from the 
mouth. Shooting pain from the tonsil into the ear. After eat- 
ing solids, a sensation as though crumbs of food had remained 
in the throat, causing irritation. Worse in the morning.— Kali 
iodatum. Coryza, with sneezing, lachrymation, and watery, 
acrid nasal discharge. Burning, scraping roughness in the 



714 DISEASES OF THE DIGESTIVE ORGANS. 

throat; dryness and itching in the throat; greenish, stringy, 
salty expectoration.— Kali muriaticum. The throat is pale 
and anaemic and the mucous membrane thickened. Thick, 
tough, white mucus in the throat and from posterior nares, 
difficult to dislodge ; crusts in the vault of the pharynx. Gran- 
ular pharyngitis. Adenoid vegetations.— Lachesis. Not so 
often indicated here as in other throat affections, but occasion- 
ally rendering excellent service, especially in acute and subacute 
cases, when the constitutional symptoms completely over- 
shadow the local affection. There is great lassitude, headache 
and general indisposition ; the throat feels constricted ; sensa- 
tion of a plug in the throat ; constant desire to swallow, with 
difficult and painful deglutition and pain extending into the 
(left) ear. Hawking of tenacious mucus. Throat livid, dusky 
red, puffed, dry. — Lycopodium. In chronic cases, with de- 
rangement of the gastro-intestinal mucous membrane; the 
fauces appear brownish-red ; d^ness and sense of contraction in 
the pharynx, with hawking of hard, greenish-yellow phlegm. 
Worse on the right side.— Magnesia phosphorica. "Hyper- 
trophy of pharyngeal structures ; choking after deglutition ; 
spasmodic cough." — Mercurtus biniodat. In cases where 
there is much inflammatory action, even though its history be 
chronic. Throat feels sore and scalded, particularly early in 
the morning on first waking and during (empty) swallowing; 
the parts look "angry" or dark-red; there is induration of ton- 
sils, elongation of uvula, and some swelling of the cervical 
glands. Hoarseness and huskiness of the voice, even to apho- 
nia. Hawking of tough, white mucus or of greenish lumps ; 
the naso-pharynx is covered with tough white or greenish 
mucus. Presence of cheesy masses in the throat. Pt3'alism; 
fetor of breath.— Mercurius protoiodat. More marked in- 
volvement of glandular structure; base of tongue covered with 
thick, dirt}', yellow coating. Right side. — Natrum muriati- 
cum. Throat dry, glazed and smarting, although there is con- 
stant hacking of thin transparent mucus. Elongation cf the 
uvula. Hoarseness. After the topical use of nitrate of silver. 
Tobacco-smokers' sore throat.— Nux vomica. Very useful in 
essentially chronic cases with derangement of the gastro-intes- 
tinal mucous membrane. Dryness, rawness and smarting in the 
throat ; scraping in the throat, especially in the morning ; he is 



FOLLICULAR PHARYNGITIS. 715 

constantly making efforts to clear it. Loose cough, with thick 
grayish expectoration and sensitiveness to pressure in the su- 
prasternal notch. Catarrhal headaches.— Phosphorus. To be 
carefully considered when laryngeal and pulmonary (tubercular) 
symptoms are present. The throat is dry and glistens ; there is 
rawness and scraping ; hawking of lumps of white, transparent 
mucus. Hoarseness; aphonia when he talks long. — Phyto- 
lacca. In the acute form, with glandular involvement ; dry- 
ness, roughness and smarting in the throat ; swelling of soft 
palate and tonsils ; tenacious, thick saliva in the throat ; dark 
bluish redness or ulceration of the mucous membrane, with co- 
pious flow of tough, ropy saliva. Pain in the ear when swal- 
lowing, as though caused by difficulty of swallowing from great 
dryness in the throat.— Plumbum. Inflammation extends from 
right to left. Tonsils covered with small abscesses. Spasmodic 
contraction of the fauces. Angina granulosa. — Pulsatilla. 
In the acute form. Bluish redness of pharynx, tonsils and 
uvula, with swelling of the parts ; sensation of a lump in the 
throat ; cough, which may be dry or followed by copious expec- 
toration and dyspnoea. More often indicated by its character- 
istic constitutional symptoms, as: burning fever without thirst, 
chilliness, amelioration in the open air. — Rhus toxicodendron. 
Hoarseness from overexerting the voice, growing less as he 
continues talking; the throat feels sore and stiff; roughness and 
soreness in the larynx. Dryness of the mouth, not relieved by 
drinking. Sticking pains when swallowing.— Sanguinaria. 
Throat feels exceedingly dry and burning, not better from 
drinking ; redness of the throat ; ulcerated sore throat. Coryza, 
with frontal headache, heat in the head, great dryness of the 
throat, and hard painful paroxysms of coughing without ex- 
pectoration.— Sanguinaria nitr. "My sheet anchor in chronic 
follicular pharyngitis ; the remedy to use in the absence of clear 
indications for another (Ivins)."— Sulphur. Great dryness 
and burning in the throat, first right side, then left, with elon- 
gation of the uvula. Study chiefly the constitutional symp- 
toms.— Wyethia. A comparatively new remedy which has 
proved of value in the chronic forms with pricking, dry burning 
sensation in the posterior nares and throat, and with a ten- 
dency to atrophy of the pharyngeal mucosa. The appearance 
of the throat is dark red; there is considerable sensitiveness, 



716 DISEASES OF THE DIGESTIVE ORGANS. 

with frequent desire to swallow, to relieve the dryness ; swal- 
lowing is often difficult ; much hawking and scraping. 

ULCERATION OF THE PHARYNX. 

Ulceration of the pharynx is of common occurrence and, as a 
symptom, varies greatly in severity and importance in propor- 
tion to the constitutional disease of which it often is a local ex- 
pression. In the follicular f orm the ulcers are insignificant as 
to size and depth, and disappear with the removal of the chronic 
catarrh of which they usually are an accompaniment. It is 
only in very exceptional cases that they require special atten- 
tion. The ulcerations which are seen in eruptive fevers, as va- 
riola, or in typhoid fever , are either the result of the general 
systemic infection or of existing cachexia. By their occasional 
severity they add much to the discomfort of the patient. If of 
cachectic origin, their appearance enhances the gravity of the 
prognosis. Cleanliness and the use of bland, soothing applica- 
tions are important features of their management. In the great 
majority of cases, however, the}' furnish additional indications 
for the exhibition of remedies which have been discussed under 
appropriate headings, as: Arsenicum, Mercury, Lachesis, 
the mineral acids, etc. The character of diphtheritic ulcera- 
tions has been considered ; a tendency to ulceration of the 
pharynx is peculiar to all pseudo-membranous affections. Can- 
cerous ulceration occurs during the ulcerative period of cancer- 
ous growths, and usually is very painful. Relief may be af- 
forded by the use of soothing, disinfecting washes and sprays. 
The ulcers of lupus may be superficial or perforating, with hard, 
everted edges and excavated base; they frequently are of con- 
siderable depth, surrounded D3- a slight areola, healing slowly 
and leaving behind contractions of cicatricial tissue, with much 
sensitiveness. Curettement or the galvano-cauter\^ are em- 
ployed for the removal of diseased tissue, followed by the free 
use of a fifty per cent, solution of lactic acid. Tuberculous ulcer- 
ation is usually secondary, irregular, with ill-defined edges and 
grayish-yellow base. "It may show itself in grayish, shallow 
lenticular ulcerations or granulations distributed over the 
pharynx, faucial region, or palate ; or in a deposit of miliary 
tubercles, which may degenerate, if the patient survive so 



HERPETIC PHARYNGITIS. 717 

long." (Ivins.) The ulcers appear oftener in the later stages 
of the disease, develop slowly, are very painful, and at their 
base are covered with sticky, yellowish debris ; the parts seem 
worm-eaten ; deglutition is painful, sometimes almost impossi- 
ble from the pain caused by it. Local treatment consists of 
cleansing and dusting the parts with powdered iodol or boric 
acid, or "spraying with a forty per cent, solution of lactic acid, 
a fifteen per cent, solution of peroxide of hydrogen, a twenty 
per cent, solution of calendula, or a ten per cent, solution of 
resorcin or menthol." (Ivins.) Of these, peroxide of hydrogen 
is most useful. Spraying with a two per cent, solution of hydro- 
chlorate of cocaine, some ten or fifteen minutes before a meal, 
may enable the patient to eat with some comfort, and thus is of 
great practical value. Starch, containing a minute quantity of 
morphia ( T V to T V of a grain), insufflated, may serve the same 
purpose when cocaine has failed. Curettement is advised by 
some authorities. Syphilitic ulceration in the secondary form 
occurs as erosions, in connection with mucous patches, grayish- 
white, superficial, and shallow ; in the tertiary form it is the re - 
suit of erosion and destruction of the gummata, and here the 
ulcers are deep, with smooth or ragged edges, surrounded by a 
bright zone; the surface, after healing, looks whitish and 
glazed, with a white, distorted cicatrix. Extensive oedema of 
the pharynx may be present and the destruction of tissue be 
great. In addition to the specific constitutional treatment, 
oftenest the exhibition of potassium iodide or mercury, the 
local use of a weak solution of potassium permanganate or of 
boric acid is advisable, chiefly to cleanse the parts. Iodoform, 
insufflated, though objectionable to many patients, often acts 
well; iodol or boric acid are less unpleasant. Ivins speaks 
highly of the following application : metallic iodine, grs. 15 ; 
alcohol, q. s.; glycerine, ,$i, to be used two or three times daily, 
the parts having been thoroughly cleansed with the spray, 
gargle, or post-nasal syringe. 

HERPETIC PHARYNGITIS. 

Also known as membranous, diphtheritic or aphthous sore 
throat. An affection of the throat corresponding to herpes of 
the skin. It is characterized by the appearance of blisters upon 
the pharyngeal mucous membrane, in due course of time fol- 



718 DISEASES OF THE DIGESTIVE ORGANS. 

lowed hja fibrinous exudation closely resembling the diphther- 
itic membrane. It occurs at an}' period of life and at any sea- 
son of the year, but is oftener seen in young children and during 
the autumn and early spring. It is said to be infrequent in 
England ; some American writers make a similar claim for this 
county, but the larger number of observers recognize it as 
common in America. It is often seen during epidemics of diph- 
theria, as well as in connection with advanced cases of syphilis 
and phthisis. 

Symptoms. — Weariness, general indisposition and loss of ap- 
petite, continuing for a few days, are followed by a sense of cold- 
ness or a chill, which soon gives way to high fever, with a tem- 
perature of 100° to 103° and a pulse-beat of from 100 to 140 
per minute, accompanied by frontal or supraorbital headache, 
sometimes nausea and slight vomiting, and almost always 
aching in the back and legs. The tongue is badly coated and 
the breath offensive ; the throat becomes sore, dry and hot, 
sometimes extending into the nares and larynx, with much dif- 
ficulty of swallowing and accumulation of thick tenacious 
mucus or copious salivation. 

Examination of the throat in the early stage shows the mu- 
cous membrane red, swollen, and covered with a fine eruption 
of vesicles, about as large as a millet-seed, whitish, and usually 
occurring singly or in groups, but confluent in bad cases. Each 
vesicle is surrounded by a zone of inflammation, and en its sum- 
mit presents a dark spot. These vesicles may be reabsorbed or 
burst. If the latter, a small, circular, superficial ulcer forms, 
which may heal spontaneously or, if not, will in a few hours be 
covered by a whitish or yellowish-white fibrinous deposit, 
which, coalescing with others, soon forms patches of psuedo- 
membrane which closely resemble diphtheria. In a few days the 
ulcers heal, and the loosened membrane is thrown off. The 
tonsils, pillars of the fauces and the soft palate are the parts 
usually affected. A considerable degree of oedema may be 
present. Deafness from involvement of the Eustachian tubes, 
and hoarseness and cough from extension into the larynx, are 
not infrequent. Throughout the attack prostration is a 
marked feature. 

The course of the disease in the average case is toward a 
rapid recovery, the intensity of the sj^mptoms, in a majority of 



HERPETIC PHARYNGITIS. 719 

cases, abating within forty-eight hours. Complete recovery in 
these takes place in a week to ten days. But when there is a 
pronounced scrofulous diathesis or a cachectic condition, a 
series of relapses may indefinitely delay recovery and prove se- 
rious from their very tediousness. When the affection occurs 
during an epidemic of diphtheria, its course must be closely 
watched, partly because it may assume all the dangerous char- 
acteristics of this more serious disease, and partly because a 
clear differentiation between the two is not always possible. 
Gangrene of the throat is an infrequent, but dreaded, complica- 
tion. 

The differential diagnosis from diphtheria presents many 
difficulties and is not always possible. If seen early, the her- 
petic character of the eruption is almost decisive, especially so 
since herpetic pharyngitis is practically limited to the tonsils, 
pillars of the fauces, and soft palate; the rapid improvement of 
the constitutional symptoms under appropriate treatment also 
tends to establish a diagnosis of herpetic pharyngitis. If the 
early stage has passed when the physician is called in, and the 
constitutional symptoms are pronounced, with great prostra- 
tion, and the case stubbornly drags along, as it may do in 
scrawny, debilitated and scrofulous children, a clear diagnosis 
cannot easily be made, and, as stated, may become impossible. 

Treatment.— If the patient is seen during the early stage, 
Aconite or Gelsemium are likely to be indicated, the former by 
its restlessness, quick and hard pulse, and great bodily heat ; 
the latter, by its aching in back and limbs, headache, more 
moderate fever, often preceded by slight shivering, watery dis- 
charge from nose and eyes, with dryness, swelling and redness 
of the fauces.— Belladonna has more marked symptoms of 
general and local congestion. The throat is bright red, very 
dry, and swallowing is exceedingly painful. The right side 
usually is first affected or is worse than the left. The speech is 
nasal, as in tonsillitis. The cervical glands are swollen and 
hard, and there is stiffness of the neck.— Apis is of great benefit 
when the onset of the disease has been insidious and not char- 
acterized by much local or general congestion, the cedematous 
tendency constituting the most striking feature of the case, and 
giving rise to much difficulty of breathing and swallowing, 
drink or liquid food often returning through the nose. The 



720 DISEASES OF THE DIGESTIVE ORGANS. 

throat looks puffed and as though varnished, and is studded 
with blisters and membranous patches. Stitching pain in the 
throat, between the acts of swallowing. "Rose-colored, red 
rash upon the skin." — Argentum nitricum has painful dryness 
in the throat, with sense of constriction, ulceration in the 
throat, and pain as though a splinter were sticking into it; 
thick, tough mucus in the throat. — Kali bichromicum is re- 
commended when there is an accumulation of stringy, ten- 
acious mucus in the throat ; stitching pains in the ears during 
deglutition ; smarting, raw feeling in the posterior nares ; ten- 
dency of the exudation to extend into the air-passages ; violent 
supraorbital headache. — Capsicum has burning soreness in 
the throat, with ulceration on the fauces ; white spots on the 
throat ; dry, convulsive and painful cough ; feeling of fulness 
in the uvula and sense of "contraction in the curtain of the 
palate during deglutition." Great thirst for cold water, 
with sensitiveness to cold in any form ; even a drink of cold 
water, though craved, makes the child shudder.— Mercurpus 
iodatus is often indicated. Both iodides of mercury are im- 
portant remedies here. The inflammation is severe ; the throat 
very painful (burning, lancinating pain), often rendering swal- 
lowing impossible. The tonsils are intensely inflamed and 
studded with ulcerations; there is usually considerable involve- 
ment of the glands of the neck and the patient is annoyed by 
the presence of tough, stringy mucus in the throat. The yel- 
low iodide is preferable when the base of the tongue is coated 
with a triangular, thick yellow coating ; the breath is very fetid ; 
loose, rattling laryngeal or bronchial cough ; preference for the 
right side. The red iodide is said to have a preference for the 
left side of the throat, and has greater intensity of the ulcera- 
tive process, with correspondingly severe pain. 

If the symptoms of the case resemble those of diphtheria, 
Baptisia, Lachesis, Arsenic, Crotalus, and other remedies 
given under diphtheria, must be consulted. If relapses are fre- 
quent, Calcarea carbonica and the antipsorics must be care- 
fully studied. 

The use of gargles and mouth-washes is not only annoying 
to the patient, but accomplishes little, if any, good. If for 
some reason they are desirable, weak solutions of hydrastis or 
of some of the potash-preparations, as the permanganate, are 



PHLEGMONOUS PHARYNGITIS. 721 

preferable. Nourishment will necessarily be given in liquid 
form, and in serious cases must be made the subject of special 
care and attention. 

PHLEGMONOUS PHARYNGITIS. 

Also called peritonsillitis or peritonsillar abscess. A danger- 
ous affection of the throat, of bacterial origin, involving the 
mucous membrane and the submucous and peritonsillar tissues. 
It may result from cold, especially in persons who are weak or 
cachectic, or appear in connection with other infectious diseases 
(as typhoid fever, measles), or it may follow an injury to the 
parts (use of the cautery, a scald, an operation). The tendency 
is to rapid and extensive ulceration. 

Symptoms.— The onset of the disease is violent. A severe 
headache, sudden in its appearance, and accompanied with a 
sense of marked indisposition, is followed by a hard chill, high 
fever, with quick hard pulse and a temperature of 103°, or 
more, severe aching in the back of the neck, back and limbs, 
and not infrequently, especially in children, delirium. Pain 
and soreness in the throat promptly declare themselves, with 
sense of obstruction in the throat and painful swallowing. 
The local symptoms are intense and grow worse rapidly. At 
first there is much dryness in the throat ; this, however, yields 
to an accumulation of offensive, tough, stringy mucus, soon 
becoming muco-purulent. The pain in the throat is intense. 
The parts are so badly swollen that the most painful efforts at 
deglutition prove useless. Food is regurgitated and breathing 
becomes seriously embarrassed, especially during sleep. The 
tongue is coated and the breath very offensive. The voice is dis- 
tinctly nasal. Earache is frequent and persistent. Painful 
swelling of the glands of the neck is often present, and the in- 
flammatory action may be sufficiently severe to extend to and 
involve the articulation of the jaw, rendering it impossible for 
the patient to open or completely close the mouth. The suffer- 
ing caused by the pain ; the inability to take nourishment and 
to breathe freely ; the restlessness and sleeplessness at night- 
all these combine to render the condition of the patient one of 
absolute wretchedness and to produce an extreme degree of ex- 
haustion. 

The throat, upon examination, presents a dark purplish hue 
46 



722 DISEASES OF THE DIGESTIVE ORGANS. 

and a condition of extensive oedema, at times practically fixing 
the soft palate and obliterating the fauces. The swelling may 
completely fill the naso-pharynx or extend into the larynx, in 
the latter case giving rise to dyspnoea which is at times suffi- 
ciently severe to demand operative interference. Submucous 
haemorrhage is not infrequent. The tonsils, though swollen, are 
not deeply involved. 

Reabsorption of the infiltration may take place, and with it 
a gradual recovery. In the larger number of cases pus forms, 
with an accompanying aggravation of symptoms until evacu- 
ation of the abscess occurs from spontaneous rupture or inci- 
sion. The former more often takes place in the anterior pala- 
tine arch, and is usually brought about by some exertion of the 
affected parts, as coughing or attempts to swallow. Imme- 
diate relief of local and constitutional symptoms follows the 
evacuation of pus. 

The duration of the disease is from four to fourteen days, 
unless both sides of the pharynx, one after the other, become 
involved, or relapses occur, or burrowing of pus has taken 
place in the deep cellular tissue of the throat, external neck, 
oesophagus or mediastinum, in which case recovery will be in- 
definitely prolonged or jeopardized. Among the possible com- 
plications, ulcerative erosion of the great blood-vessels and gen- 
eral blood-poisoning are the most serious. 

Treatment. — The first and chief aim must be to bring about 
resolution by reabsorption of the infiltration, and for that pur- 
pose applications of ice and ice-cold water have been recom- 
mended, without, however, yielding satisfactory results. It is 
better practice to hasten suppuration by the use of moist heat 
(hot fomentations around the neck, hot gargles, hot inhala- 
tions) and then insure prompt evacuation of the abscess. For 
the latter purpose a bistoury of which all but half an inch, or 
so, of the blade has been protected by a wrapping of adhesive 
plaster or tissue-paper may be used if a pharyngeal knife is not 
at hand. The tongue of the patient is controlled by a depres- 
sor, and the operation performed by inserting the knife flat, the 
cutting edge toward the median line, enlarging the cut toward 
the median line before withdrawing the knife. By this means 
the incision will be made large enough to insure the escape of 
all the contents of the abscess, and there is slight danger of 



PHLEGMONOUS PHARYNGITIS. 723 

wounding important vessels. If it is difficult to detect fluctua- 
tion, the method first suggested by Stoerk may be employed. 
" Put the fingers of one hand externally under the angle of the 
lower jaw, pressing the skin and all the tissues inwardly, while 
the index finger of the other hand moves slowly over the infil- 
trated parts, beginning high up on the soft palate and sliding 
downward toward the tongue. When the two index fingers 
moving and pressing toward each other meet in a spot where 
the tissues offer less resistance, imparting a doughy sensation, 
this is the point for the incision." 

The pain frequently is so intense that most earnest appeals 
for temporary relief are made. Morphine is objectionable. If 
the attending physician deems it best to use a narcotic, salol 
may be given in doses of ten to fifteen grains every three hours; 
children can take this drug in doses of from two to ten grains. 
Antipyrine and phenacetine have also been used, sometimes in 
combination with salol. 

Occasionally, pus-formation progressing slowly, and the pa- 
tient's condition being serious, suppuration may be hastened and 
some temporary relief given by making a number of free inci- 
sions; this procedure is not free from danger since sloughing 
may result. In extreme cases tonsillotomy or tracheotomy 
may have to be performed for the relief of dangerous dyspnoea. 

Therapeutics. — Aconite is undoubtedly of value if the pa- 
tient is seen early. — Belladonna, indicated by its characteris- 
tics, follows Aconite.— Cantharides should be carefully 
studied because of the intensity of its action upon the pharyn- 
geal mucous membrane. The throat feels on fire ; constriction 
amounting almost to suffocative dyspnoea.— Ailanthus. Great 
swelling of the throat, internally and externally. Throat 
dusky-red. Ichorous discharge. Delirium. Stupor and indiffer- 
ence. Coldness of the tip of the nose and extremities. — Apis is 
suggested by extensive oedema of the parts, and is valuable 
when there is stupor and great prostration. Severe stinging 
pains when attempting to swallow.— Mercury is of import- 
ance, and the iodides of mercury, given at short intervals, 
have done excellent service.— Mercurius corrosivus has in- 
tense inflammation and ulceration of the throat, with violent 
burning pain, extensive swelling threatening suffocation, and 
general phlegmonous tendency. — The usefulness of Silica, Ar- 



724 DISEASES OF THE DIGESTIVE ORGANS. 

senic and Hepar sulph. depends upon their influence upon 
the suppurative process.— Rhus, Arsenic, Baptisia, Carbo 
vegetabilis, and others of this class, come into play when the 
patient is in a condition of extreme prostration, with a gener- 
ally depraved, cachectic state of the system. 

ACUTE INFECTIOUS PHLEGMONOUS 
PHARYNGITIS. 

A very grave affection which was first described by Senator, 
in 1888. Its pathology consists of "diffuse purulent infiltra- 
tion of the deeper parts of the pharyngeal mucosa, continuing 
from there to the larynx, trachea, and secondarily to other 
parts of the body, e. g. the mucosa of the stomach. The lym- 
phatic glands of the neck are swollen, and the kidneys are 
sometimes enlarged, as is also the spleen. No specific micro-or- 
ganisms could be cultivated from the affected organs." 

The disease attacks persons who are in the enjoyment of ro- 
bust health. There is soreness of the throat, difficulty of swal- 
lowing, hoarseness and loss of voice, extensive oedema of the 
parts, with dyspnoea. Fever is present through the entire 
course of the disease, observers differing as to its intensity and 
the range of temperature attained. The constitutional symp- 
toms are very severe from the beginning, and suppuration takes 
place rapidly, but is not localized. A typhoid state supervenes 
in some cases, occasionally followed by coma. "The urine al- 
ways contains albumin. Death, as a rule, ensues suddenty, 
within a few days after the beginning of the disease." 

The prognosis is entirely unfavorable. So far, treatment has 
proved useless or of temporary benefit only. 

ERYSIPELATOUS PHARYNGITIS. 

An infectious disease, not differing essentially from erysipelas 
in any other part of the body, and in the larynx confined to the 
superficial structures. It may occur primarily or from exten- 
sion or metastasis from some other part of the body. Resolu- 
tion is not infrequent, but extension of the erysipelatous pro- 
cesses to the face, nasal cavity, middle ear, bronchi or lungs 
may take place and give rise to the most serious complications. 

The symptoms are those of an intense acute catarrhal phar- 



GANGRENOUS PHARYNGITIS. 725 

yngitis, sudden in onset or preceded by several days of general 
indisposition, high fever, etc. There is intense heat, dryness 
and severe pain in the throat, with hyperemia, glazed redness, 
swelling, sometimes oedema, of the parts; blisters, filled with 
serum or pus, may be seen. Salivation is common. The glands 
of the neck are moderately swollen. The constitutional symp- 
toms are marked, with a temperature of 102° to 104°, quick 
hard pulse, rapid breathing and prostration. Recovery is fol- 
lowed by desquamation of the affected mucous membrane. 

The gravity of the process depends not only upon the impair- 
ment of nutrition which is a feature here as of other pharyn- 
geal inflammations, but upon the existing oedema, resulting in 
great embarrassment of respiration, and upon the loss of 
tissue, haemorrhage, and septicaemia which are the result of 
sloughing of the parts. 

Treatment. — Close attention to cleanliness and disinfection of 
the pharynx (peroxide of hydrogen, permanganate of potash, 
alkaline sprays generally) are very important. Spraying with 
menthol or cocaine is soothing and often directly helpful. 
Lumps of ice may be sucked freely and stimulants used as indi- 
cated. CEdema of the larynx may demand the hypodermatic 
use of pilocarpine hydrochlorate (gr. ito^), scarification, or 
even tracheotomy. Proper medication is all-important, since 
the remedies capable of controlling erysipelatous inflammation 
in other parts of the body cannot but yield good results when 
the same process invades the pharynx. Hence, such remedies as 
Apis, Belladonna, Cantharides, Rhus toxicodendron, and 
others indicated by the local and constitutional symptoms, 
must be administered judiciously and with perseverance. 

GANGRENOUS PHARYNGITIS. 

Gangrenous or putrid sore throat is a rare and very serious 
affection. It may be primary, but much oftener follows scarlet 
fever, measles, diphtheria, small-pox, typhoid fever and phleg- 
monous pharyngitis, or occurs as the result of traumatism. It 
is an intense inflammation with marked gangrenous tendency, 
affecting chiefly the soft palate, tonsils and posterior walls of 
the pharynx, eventually extending downward, causing disas- 
trous laryngeal and pulmonary complications, and infecting 



726 DISEASES OF THE DIGESTIVE ORGANS. 

the stomach and intestines from swallowing particles of foul, 
gangrenous matter. 

The symptoms are those of a pharyngitis, usually violent in 
their onset and character, with the formation, in a few days, 
of dark, blackish, gangrenous spots on the affected parts; the 
gangrenous patches are surrounded by highly inflamed, livid, 
mucous tissues, the affected parts emitting a characteristic hor- 
ribly foul odor which somewhat resembles that of faecal mat- 
ter. The fever at first is high ; later the temperature drops and 
eventually becomes subnormal. The entire s\'stem is soon af- 
fected ; prostration grows excessive, the extremities grow cold, 
symptoms of collapse supervene, and death occurs, generally 
from syncope. Exceptionally recover}^ takes place. 

The diagnosis from diphtheria rests upon the greater pros- 
tration of gangrene, the characteristic odor, the blackish ap- 
pearance of the tissues, comparatively slight involvement of 
the cervical glands, and the low temperature and pulse. 

Treatment.— Ailanthus, Arsenic, Merc, corrosivus, Am- 

MON. CARB., BAPTISIA, SECALE CORNUT., CARBO VEGETAB., 

Kreasotum, Lachesis. Locally, soothing and disinfecting 
solutions must be used in the form of a spray or gargle; of 
these, peroxide of hydrogen and potass, permanganate are the 
most useful. Stimulants are indicated, and painstaking atten- 
tion to feeding, by mouth and rectum, is indispensable. 

RETRO-PHARYNGEAL ABSCESS. 

An affection chiefly of early childhood, though occasionally 
seen in adults, consisting of deep-seated inflammation of the 
posterior pharyngeal wall, resulting in the formation of pus. 
It is most frequent in delicate, scrofulous and tuberculous sub- 
jects. In the great majority of cases it is of idiopathic origin, 
the result of cold, especially from subjection to the heat of a 
very warm room after exposure to severe cold. It also occurs 
as a sequel of fevers, particularly of scarlet fever and diphtheria, 
and as a secondary affection in caries of the cervical vertebrae. 

In the common idiopathic form the onset of the disease is 
usually insidious, the patient suffering from general indisposi- 
tion, loss of appetite, restlessness and slight fever. Within a 
few days attention is called to the throat by the nasal, metallic 



RETROPHARYNGEAL ABSCESS. 727 

sound of the voice and evidence of fulness and some soreness 
in the throat, in due time accompanied with difficult, painful 
swallowing, which increases as the local symptoms become 
more and more marked. In severe cases there is interference 
with breathing, differing in degree with the severity of existing 
tumefaction and the exact location of the swelling. 

The swelling in the larger number of cases is visible and 
readily detected by the touch. It is usually on one side of the 
median line, though occasionally concealed behind the pos- 
terior nares or oesophagus, differing as to extent from an insig- 
nificant tumor to a general tumefaction often occluding the en- 
tire cavity of the pharynx. The overlying mucous membrane 
may present slight indication of severe inflammation ; when 
the inflammatory action partakes of a phlegmonous character, 
the tissues are congested, hot and dry; patches of yellow show 
where pus has formed. 

A dry, painful cough may be present ; external swelling of the 
throat is not infrequent, and chills or shivering accompany the 
formation of pus. 

Difficulty of breathing depends largely upon the site of the 
abscess ; thus, if located behind the posterior nares, dyspnoea is 
slight, but swallowing very difficult. 

When secondary, the symptoms are those of the primary af- 
fection. 

The duration of the disease is variable. The average case 
terminates in from one to two weeks. Others run a tedious 
course, especially so when the abscess is not large, is deep, and 
pus has burrowed, causing slight local symptoms, but giving 
rise to grave constitutional disturbances. Exceptionally a 
fatal termination may take place in a few days. 

Diagnosis.— The tumor can almost always be readily seen or 
felt. When it is located behind the posterior nares, the rhino- 
scope or laryngoscope may have to be employed. The symptoms 
at times resemble those of membranous croup, but the great 
difficulty of swallowing, the relief of dyspnoea usually afforded 
by sitting up, and the absence of hoarse shrillness of breathing 
and voice establish the diagnosis. The gradual development of 
labored breathing and the absence of respiratory embarrass- 
ment, especially accentuated during inspiration, distinguish it 
from oedema of the larynx; these conditions may co-exist. 



728 DISEASES OF THE DIGESTIVE ORGANS. 

Treatment. — In the early stage such remedies as Aconite, 
Belladonna, Apis, Lachesis and Mercury may be exhibited, 
according to the symptoms of the case. Usually the patient is 
not seen until pus has formed, and then Hepar sulph., Silica 
and Arsenic are indicated. Lachesis and Rhus toxicod. are 
valuable when a phlegmonous or erysipelatous condition ob- 
tains. 

Prompt evacuation of pus must be secured. A slight incision 
is at times sufficient. If the pus lies deep, considerable care must 
be used not to injure important blood-vessels. The patient's 
head must be promptly thrown forward upon the completion of 
the incision to insure the escape of the contents of the abscess 
through the mouth. It is evident that neglect to open the ab- 
scess in time may lead to burrowing of pus and serious compli- 
cations, such as involvement of the cervical vertebra? or auto- 
infection. In tedious or bad cases close attention must be paid 
to proper feeding, to sustain the strength of the patient. 

A^JGII^A LUDOVICI. 

Ludwig's angina, or cellulitis of the neck, may occur idio- 
pathically, or from trauma, or secondarily in connection with 
acute infectious fevers, especially diphtheria and scarlet fever. 
Its first expression usually is a pronounced swelling of the sub- 
maxillary glands of one side. Other glands are involved later. 
Its chief and great danger lies in systemic infection ; hence, 
prompt and radical treatment is demanded, usually free in- 
cision in the buccal region. Matignon reports successful treat- 
ment of four cases by incision in the subhyoid region. "Felix 
Semon holds that the various acute septic inflammations of the 
throat— acute oedema of the larynx, phlegmon cf the pharynx 
and larynx, and angina Ludovici— represent degrees, varying 
in virulence, of one and the same process." 



DISEASES OF THE TONSILS. 729 

DISEASES OP THE TONSILS. 
ACUTE TONSILLITIS. 

Acute tonsillitis, acute amygdalitis, angina tonsillaris, cyn- 
anche tonsillaris, quinsy, is an acute inflammation of one or 
both tonsils, superficial or deep, terminating in resolution, ab- 
scess, or chronic enlargement of the gland. 

/Etiology. — It is more frequently seen in young adults of 
twenty to thirty years of age, though observed among both 
younger and older persons. It is, however, uncommon in chil- 
dren of less than ten and in adults of more than forty -five years 
of age, except as there may exist a special predisposition to the 
affection. A strumous diathesis and inherited predisposition 
are important astiological factors, and in their presence trifling 
causes may excite an attack. Men, on account of greater ex- 
posure, furnish the larger number of cases. In damp and cold 
weather, such as favors the appearance of rheumatism, and in 
countries where severe and sudden changes of weather are the 
rule, acute tonsillitis is quite common ; the absence of these con- 
ditions, as in Southern California, renders tonsillitis a compar- 
atively rare disease and usually protects persons who in the 
Eastern states suffer from frequent attacks. The fact that 
serologically tonsillitis and rheumatism are closely related has 
always attracted the attention of the profession. It is doubt- 
ful if this relation is more than setiological, although it is well- 
known that rheumatic symptoms often precede an attack of 
quinsy, promptly disappearing as soon as the throat becomes 
sore ; on the other hand, tonsillitis may precede an attack of 
rheumatism, and both may occur together. 

Among the exciting causes sudden chilling and taking cold 
are prominent. Scarlet fever, measles, small-pox and diph- 
theria are occasionally followed by tonsillitis. In some cases, 
especially in scrofulous, strumous subjects, it is brought on by 
slight traumatism, as a foreign body (fish-bone) penetrating 
into the gland,, or by some local irritation, as from the inhala- 
tion of irritating gases. The inhalation of sewer-gas and the 



730 DISEASES OF THE DIGESTIVE ORGANS. 

use of bad -water may cause a tonsillitis which usually involves 
both tonsils, and probably is septic in character. 

The superficial form is oftener seen in children ; parenchyma- 
tous tonsillitis is largely confined to adults. 

Symptoms. — In the main, the symptoms of the superficial 
form differ from parenchimatous tonsillitis in their compara- 
tive lightness, shorter duration, and their usual termination by 
resolution. Bearing this in mind, it is not necessary to describe 
these forms separately. 

A short period of indisposition, rarely exceeding twenty-four 
hours, is followed by high fever, with a temperature which may 
reach 104° or 105° on the evening of the first day. Fulness, 
stiffness, heat, soreness and pain in the throat, with frequent 
empty swallowing, appear and increase rapidly. Examination 
of the throat discloses an enlarged tonsil, of vivid bright-red 
color; the lacunae are filled with a viscid, yellowish-white secre- 
tion ; this extends into the Eustachian tubes and inner ear> 
causing severe and stubborn earache and temporary deafness. 

Swallowing is very painful, the difficulty of deglutition in- 
creasing in proportion to the extent of tissues involved and of 
the swelling of the parts, which constant!}' lessens the calibre 
of the faucial orifice and eventually compels the return of 
liquids through the nose. The condition of the patient under 
these circumstances is distressing. The pain in the throat is 
excessive. There is copious secretion of saliva and mucus, 
which cannot be swallowed, and yet constantly excites the de- 
sire to get rid of it. The saliva is finally allowed to dribble 
from the mouth, but the rop} r , tenacious secretions keep up a 
constant involuntary hawking and painful gagging ; to take a 
drink not only involves aggravation of already severe pain and 
its probable return through the nose, but danger of its entering 
the larj-nx, giving rise to paroxysms of violent coughing and 
choking, causing intense distress. The earache in the mean- 
time continues ; smell and taste are almost lost ; the voice is 
thick and guttural; every attempt to speak is expressive of the 
dread of pain which is sure to result from each effort involving 
the use of the inflamed throat, aggravated from the fact that 
by this time the connective tissue of the throat and the glands 
at the maxillary articulation are involved, adding to the diffi- 
culty of swallowing or talking. The glands of the neck also 



ACUTE TONSILLITIS. 731 

are enlarged and sensitive to the touch, and the neck itself is 
often stiff and painful. The urine is high-colored, scanty, of 
high specific gravity; and there is headache and soreness and 
aching in the back and legs. The face bears an expression of 
intense suffering, appears drawn and haggard, and is almost 
characteristic of the disease. Great bodily exhaustion results 
from the severe suffering. 

In the simple variety of tonsillitis the symptoms resulting 
from involvement of the deeper tissues and adjacent structures 
may be wanting, but even in these the pain is very severe and 
the general picture of the disease much as described. Improve- 
ment, however, shows itself in these within five or six days, and 
resolution takes place possibly sooner. When the parenchyma 
is involved the case is more tedious, although even here resolu- 
tion may take place. However, if in the latter form decided im- 
provement does not occur within a week or ten days, suppura- 
tion may be expected. In such a case rigor, usually slight, is 
noted ; the pain continues and even increases, but in character 
becomes lancinating, pulsating, throbbing. The abscess finally 
bursts, with immediate relief of all the symptoms. 

Spontaneous evacuation of the abscess is usually into the 
mouth or pharynx. It may empty into the larynx and cause 
serious, even fatal, strangulation ; or the pus may burrow and 
either make its exit at the angle of the jaw or extend down- 
ward and through the connective tissue, finding its way into 
the mediastinum or lungs, with, of course, very serious conse- 
quences. 

In many cases of parenchymatous or suppurative tonsillitis 
the course of the disease is much more rapid, and fluctuation 
may be felt in three or four days by placing one finger on the 
tonsil and the other at the angle of the jaw. 

Diagnosis. — The symptoms of tonsillitis usually are so pro- 
nounced that the disease is readily recognized. The pinched 
appearance of the face alone is almost sufficient to establish the 
diagnosis. It is, however, often necessary to exercise care in a 
differentiation between acute tonsillitis and diphtheria. In 
tonsillitis the secretion is sticky and occurs in "patches;" these 
patches are separated by clean, inflamed tonsillar tissue ; the de- 
posit itself is on the tonsils ; it can be wiped off ; there is no ero- 
sion of the mucous membrane underlying it. In diphtheria the 



732 DISEASES OF THE DIGESTIVE ORGANS. 

membrane is not limited to the tonsils, but covers the uvula 
and soft palate as well ; the membrane is uniformly distributed 
and is of an ashy-gray color ; it cannot be wiped off ; when re- 
moved by force it comes off in flakes or strips, exposing under- 
neath a raw, bleeding and ulcerating surface. The angina of 
scarlatina is easily distinguished by the presence and character 
of the constitutional symptoms of scarlet fever, the acuteness 
and duration of the fever itself, the flushed face, the "straw- 
berry" appearance of the tongue, and the uniformity with 
which both tonsils are involved. 

Prognosis.— In the uncomplicated case an unqualified favora- 
ble prognosis can be given. Complications, however, are not 
rare, even in the simpler forms (variously divided into follicu- 
lar, lacunar, catarrhal, herpetic, ulcero-membranous) of tonsil- 
litis. 

Febrile albuminuria, endocarditis and pericarditis occasion- 
ally set in, and affections of the middle ear are common. In 
the suppurative form danger more often arises from the bur- 
rowing of pus or from strangulation caused by the bursting of 
the abscess, the contents of which are emptied into the larynx, 
or from extreme dyspnoea due to extensive laryngeal oedema, 
from haemorrhage and, very rarely, from gangrene. 

Exceptionally the course of the disease is rendered very tedi- 
ous by the recurrence of the inflammatory process on the other 
tonsil, or in strumous subjects b}' suppuration of some of the 
cervical glands. In such cases prostration becomes a serious 
factor. In nearly all cases more or less hypertrophy of the 
tonsils remains ; this applies especially to those of a strumous 
habit. 

Treatment. — Cold applications to the neck (packs of flannel 
dipped in ice-cold water, covered with oiled silk, or small ice- 
bags) are recommended in the early stage. Lumps of ice, al- 
lowed to dissolve in the mouth, are both grateful and helpful. 
Osier advises the use of dry sodium bicarbonate every hour, ap- 
plied directly to the inflamed tonsil by means of the finger 
dipped into the powder. 

Suppuration threatening, hot applications are indicated, such 
as flannels wrung out of hot water or hot infusion of the 
flowers of hops, covered with oiled silk. The use of medicated 
vapors (compound tincture of benzoin, permanganate of 



ACUTE TONSILLITIS. 733 

potash) is soothing and directly beneficial. Deep scarification 
of the tonsil is advised in bad cases with excessive swelling, 
because it relieves pain and hastens suppuration. Early evacu- 
ation of the pus should be insured by making a free incision at 
the point of fluctuation with a properly wrapped bistoury, 
carrying the incision from above downward, parallel with the 
anterior pillar. The point of fluctuation, in the majority of cases, 
is at the upper and anterior surface of the tonsil, near the ante- 
rior palatine fold. Care must be taken not to wound the an- 
terior arch of the palate. After the evacuation of the pus, per- 
oxide of hydrogen or thymo-hydrastis should be used as a gargle 
until healing has taken place. Excision of the tonsil and even 
tracheotomy may become necessary if the swelling, in the ante- 
suppurative stage, is so great as to threaten suffocation. If 
the patient desires drink, lemonade is usually more grateful 
than water and aids in " cutting" the phlegm. Especial pains 
must be had to support the system by nourishing diet. The ap- 
plication of cocaine to the inflamed parts, by means of a 
camel's-hair brush, often enables the patient to swallow when 
otherwise this would be impossible ; the practice is objection- 
able on account of the dryness of the parts which is likely to 
follow the use of cocaine. 

Therapeutics.— Aconite is an excellent remedy in the early 
stage of the disease. Its action is so satisfactory that it has 
become a routine prescription with the physiological school. 
— Belladonna, beyond doubt, controls more cases, prior to 
the stage of suppuration, than all other remedies. Its indi- 
cations are perfectly familiar to all. The lower attenuations 
have proved much more useful here than the high.— Merctjrius 
is of the greatest value when there is severe inflammation of 
the gland-substance. It covers to perfection the symptoms of 
a large number of such cases, and the statement made by E. M. 
Hale (Practice of Medicine) that it frequently aborts quinsy is 
based upon facts. The Iodides of Mercury are more fre- 
quently called for, but in very severe cases the Mercurdjs cor- 
rosivus or the Merc, cyanat. may be used advantageously. 

In addition the following must be consulted: Apis. Great 
oedema of the parts, with dyspnoea ; difficulty of keeping any- 
thing about the throat, on account of the feeling of distress 
caused by it ; dryness of the mouth and throat ; stinging, burn- 



734 DISEASES OF THE DIGESTIVE ORGANS. 

ing pain in the throat; absence of thirst; albuminous urine. — 
Lachesis. Great sensitiveness to touch or slight pressure 
about the neck; sharp pain in the throat, on the left side, ex- 
tending into the ear ; throat livid, purple ; great difficulty in 
swallowing; fluids regurgitate through the nose; swelling of 
cervical and submaxillary glands. Great prostration.— Phy- 
tolacca. Great rawness and roughness of the throat, espe- 
cially on the right side, with backache, headache and muscular 
stiffness. Purplish appearance of the throat ; pain at the root 
of the tongue, running into the ears, when swallowing. Abun- 
dant secretion of tough, stringy mucus in the mouth and 
throat. Urine dark, scanty, albuminous. Great weakness. — 
Rhus toxicodendron. Throat swollen, vivid, covered with 
(yellow) membrane. The muscles of the throat are sore and 
stiff. Rheumatic lameness, aching and bruised soreness in the 
muscles. Sticking or stinging pain in the tonsils. — Guaiacum. 
Violent burning in the throat. Intense headache. Putrid 
taste in the mouth. The case tends toward rapid suppuration. 
In the early part of the disease.— Ferrum phosphoricum. Re- 
sembles Aconite in its sphere of action, but lacks the intensity 
of the latter. Recommended by Fisher (Diseases of Children). — 
Kaxi bichromicum. "Tonsillitis herpetica with membranous 
exudation, inflammation of uvula and pharynx, foul yellow 
tongue; fauces covered with ropy mucus; Eustachian tubes 
blocked up ; pain shoots from ear down to the throat. (Lilien- 
thal.) To be considered in cases which resemble diphtheria. 

The stage of suppuration demands the exhibition of Hepar 
sulph. (sensitiveness to cold ; stitches in the throat extending 
into the ears, sensation of fish-bone or splinter in the throat), 
Silica (on the left side; pricking in the throat as from a pin), 
Sulphur (abscess refuses to heal), and antipsorics generally. 

CHRONIC TONSILLITIS. 

Chronic tonsillitis, also described as chronic amygdalitis and 
hypertrophy of the tonsil, from the frequency of its occurrence 
and the serious and far-reaching character of the constitutional 
symptoms which accompany it, has received very painstaking 
attention at the hands of the profession. The belief is now gen- 
erally entertained that a majority of the serious disturbances 



CHRONIC TONSILLITIS. 735 

noted in connection with hypertrophy of the tonsils are only in 
part due to the tonsillar enlargement, but depend upon a group 
of structural changes, chiefly in the nares and naso-pharynx, 
with which chronic tonsillitis is almost invariably associated, 
but which the enlarged tonsil alone— either by pressure upon ad- 
jacent structures, or by its acting as a means of obstruction, or 
by inability to perform its physiological function — cannot pos- 
sibly cause. It is because of this now generally accepted 
opinion that recent writers show a tendency to discuss chronic 
tonsillitis in connection with the broader subject of "mouth- 
breathing." But in all these cases enlargement of the tonsils 
exists, and requires attention. 

Pathologically, the enlarged gland may be hard (fibrinous) 
or soft (adenoid). The adenoid form is the more frequent. It 
is usually seen in children, and is associated with adenoid vege- 
tation in the naso-pharynx. It involves the mucous membrane 
of the follicles rather than the substance of the glands, and un- 
dergoes atrophy earlier and much more completely than does 
the fibrinous form. The tonsillary enlargement is usually well- 
marked, but becomes excessive only when the gland is acutely 
inflamed. Hard or fibrous hypertrophy commonly results from 
repeated attacks of tonsillar inflammation, and is slower than 
the adenoid form to cause pharyngeal disturbances. 

Clinically, according to Chs. H. Knight, three forms may be 
recognized. 

1) A very marked hypertrophy, accompanied with difficult 
deglutition and respiration. The cause of the latter, and also 
of the ear-troubles so frequently seen in this connection, is not 
due to the enlargement of the tonsil, but to adenoid growths 
in the nasal fauces and vault of the pharynx. Mouth -breathing 
here is a conspicuous and troublesome symptom. 

2) A flat, diffuse hypertrophy, only slightly projecting into 
the fauces, but becoming prominent during the act of retching. 
This type occurs most frequently in persons of a rheumatic dia- 
thesis, and is characterized by a pronounced tendency to re- 
curring inflammation with liability to suppuration, not within 
the body of the tonsils, but in the adjacent cellular tissues. 

3) Enlarged tonsils, bound down by adhesions, the result of 
inflammation, of the anterior pillar. Here "the tonsil carries 
with it the palato-glossal fold, which may be much thicker 



736 DISEASES OF THE DIGESTIVE ORGANS. 

than normal or may be spread out over the surface of the ton- 
sil in a thin veil of mucous membrane." 

Release of the tonsil from the pillar results, according to 
Cohen, in diminution of its size. 

The adenoid growths spring from the mucous membrane of 
the vault of the pharynx, are usually papillomatous, with 
lymphoid parenchyma, sessile or pedunculated, or of a moder- 
ate degree of firmness, reddish, freely supplied with blood- 
vessels, and as large as a pea, sometimes larger. Chronic nasal 
catarrh almost always exists when these growths are present. 

Hypertrophy of the tonsils is a disease of childhood, rarely 
first appearing in adult life, and is probably a common expres- 
sion of physical weakness and of a strumous diathesis. It is 
not infrequently observed in very young children, though prob- 
ably never congenital. There is in a great majority of cases a 
history of previous inflammation, not necessarily of attacks of 
marked severity. 

Symp oms.— The symptoms of chronic tonsillitis, using the 
term in the broad sense previously indicated, differ very much, 
ranging from slight and perhaps occasional local irritation 
with trifling constitutional disturbances to a condition which 
is justly alarming. The physician, of course, rarely deals with 
the lightest cases, since some appreciable deviation from health 
is sure to exist before he is consulted. 

Mouth-breathing is one of the earliest and most constant 
symptoms present, and its effects are far-reaching. It is rarely 
due to any very great obstruction to breathing from the tonsil- 
lar enlargement alone, but depends upon the fulness of the 
pharynx which is immensely emphasized by the presence of 
chronic nasal catarrh and adenoid vegetations in the naso- 
pharynx. That these latter are found in very many young 
children has been amply demonstrated in both Europe and 
America. Natural breathing being obstructed and growing 
tiresome, the child unconsciously seeks relief by breathing 
through the mouth. If well-marked in infants, it is usual and 
natural to find associated with it considerable difficulty of 
swallowing, nursing at the breast being particularly trying. A 
young babe, thus affected, will cough, snort and choke until it 
becomes exhausted; lack of food alone in such cases becomes a 
serious cause of trouble. 



CHRONIC TONSILLITIS. 737 

Mouth-breathing in young children is best studied at night, 
when asleep. The sleep is disturbed by evident uneasiness and 
vague consciousness of discomfort. The jaw drops ; the respi- 
rations are irregular and hard, interrupted by a brief cessation 
of all respiratory effort, to be followed by a deep inspiration 
and momentary relief. The heart's action corresponds to the 
breathing ; it slows as inspiratory effort is light, and increases 
as breathing is more active and regular. The effort constantly 
made finds an expression in the contraction of the alaa nasi. 
The child is restless, tumbles about in bed, and frequently 
suffers from what nurses aptly call night-terrors. Peculiar 
changes in the appearance of a child thus affected take place in 
due season. The face not only assumes an unintelligent expres- 
sion from the habitual dropping of the jaw, but eventually the 
nostril becomes pinched in appearance, the lips thickened, and 
the expression of the countenance stupid and disagreeable. 
More than this, the intelligence of the little patient appears to 
wane ; the child grows slow of comprehension, lacks in energy, 
moves listlessly, is sullen and morose. Proper treatment at 
this time, consisting chiefly of the removal of the adenoid 
growths, produces startling results for the better, often in a 
surprisingly short time. There is considerable cough in many 
of these cases, short and paroxysmal in character, sometimes 
brought on upon assuming some particular position in bed. 
The voice becomes nasal, with difficulty of pronouncing certain 
letters, as 1, r, m, and n. Hearing is impaired, sometimes from 
insufficient supply of air in the upper larynx, causing retraction 
of the tympanum, but more often from extension of a low in- 
flammatory process into the Eustachian tubes or from nar- 
rowing of the Eustachian orifice by adenoid growths. 

Headache, loss of appetite, impairment of smell and taste, 
hawking and swallowing of glairy pharyngeal mucus, irrita- 
bility of the nervous system, enuresis and minor and irregularly 
appearing nervous troubles are among the concomitants. 

The foulness of the breath is marked. This arises from the 
presence of retained secretions in the tonsillar crypts, which in 
due time may result in the deposit of lime salts and the forma- 
tion of tonsillar calculus. Certain changes in the appearance 
of the thorax were first described by Dupuytren, consisting of 
depression of the ribs on one side and a proportionate protru- 
47 



738 DISEASES OF THE DIGESTIVE ORGANS. 

sion of the sternum in front. Since then, these have been made 
the subject of extended observation, and elaborate descriptions 
of the "chicken-breast," "barrel-chest" and "funnel-breast" 
have been furnished. 

Treatment.— The weight of evidence, as given by eminent 
clinicians and by practitioners whose experience as specialists 
in diseases of the throat cannot be ignored, is in favor of oper- 
ative interference, consisting of the prompt removal of all 
adenoid growths and of the enlarged tonsil. The argument ad- 
vanced in support of this position rests upon the comparative 
uselessness of constitutional treatment or of local measures 
which stop short of a radical cure, and upon the immediate re- 
lief often afforded by surgical procedures of most distressing 
symptoms which had existed for a long period of time and had 
greatly affected the general health. The soundness of this 
teaching cannot be denied, especially in view of the fact that 
with the growth of the specialty devoted to affections of the 
throat cures have thus been achieved which would have been 
considered impossible a few decades ago. 

On the other hand it must be conceded that the primary 
cause, the essential pathology of this affection, lies in a consti- 
tutional dyscrasia of which the growths upon the nasopharyn- 
geal mucous membrane, the chronic nasal catarrh and the 
tonsillar hypertrophy are but local expressions. If so, the re- 
moval of the offending structures, while it may and certainly 
often does give prompt, and perhaps immediate, relief of symp- 
toms which it as yet seems impossible to reach by other means, 
does not in am' sense constitute a cure of the patient. In fact, 
even specialists do not deny the recurrence of these growths 
and the necessity of repeating the operation in many cases. 
Furthermore, while we cannot refuse to accept the testimony 
in favor of radical surgical treatment, we have on the other 
hand no right to ignore the voice of those who earnestly affirm 
to have made cures by the exhibition of the indicated remedy 
alone. 

Beyond doubt truth lies between the two extremes, and the 
indications for the most successful treatment are the prompt 
removal of morbid growths as soon as the uselessness of more 
conservative treatment has been demonstrated, and the eradi- 
cation of the constitutional bias of the patient which is the 



CHRONIC TONSILLITIS. 739 

first and real cause of the difficulty. The former must not be 
delayed beyond the point of wisdom, and if the condition of 
the patient demands it, no hesitancy should be felt as to an im- 
mediate operation. Unwillingness to resort to surgical methods 
when these alone can give prompt relief is no less wrong than 
a determination to operate whenever an excuse for it may be 
found. 

The power of the indicated remedy to modify and remove the 
constitutional tendency or taint which is responsible for the ex- 
istence of the local affection has been amply demonstrated. 
The remedies most likely to accomplish this task are the 
deeply acting antipsorics and those which, like the iodides, have 
a specific action upon the glandular tissue. The most impor- 
tant are Calcarea iodata, Baryta iodata, Mercurius 
iodatus and Arsenicum iodatum. 

Calcarea iodata acts well when there is tendency to gland- 
ular enlargement and a sluggish temperament ; fat, flabby chil- 
dren, late in learning to walk ; profuse sweating, especially about 
the head; coldness of the extremities; feebleness of memory and 
mental dulness; eczematous condition; dull, heavy headache; 
scrofulous ophthalmia; hardness of hearing; muco-purulent 
discharge from the ear; nasal catarrh, with swelling at the 
root of the nose and thick, fetid discharge ; ravenous hunger, 
with chronic indigestion and desire for chalk, hard boiled eggs, 
and indigestible substances. Characteristic diarrhoea; ten- 
dency to laryngeal catarrh. — Baryta iodata. Malnutrition; 
child mentally weak and backward ; takes cold easily ; nasal 
catarrh, with involvement of the middle ear; tendency to 
laryngeal catarrh; "habitual colic of children who do not 
thrive, who seem hungry but refuse food ; " constipation with 
hard, knotty stools; sweating of the feet.— Mercur. iodat. 
play. Particularly useful in cases where there is marked 
chronic post-nasal catarrh; the throat shows a pronounced 
tendency to suppurative inflammation from slight colds. — 
Arsenicum iodat. "The child is unevenly developed ; emaciated 
limbs, with well-developed trunk ; head large, neck small, ab- 
domen distended. Tubercular habit, rachitic dyscrasia" 
(Fisher). Dark complexion ; scrawny ; skin dry, harsh, eczema- 
tous. Irritable. 

Other remedies to be studied are: Lycopodium, Sulphur, 



740 



DISEASES OF THE DIGESTIVE ORGANS. 



Psorinum. The diet must be sustaining, digestible and selected 
with reference to the especial needs of each case. Cod-liver oil, 
regularly given for a long time, is helpful. In fact, everything 
must be done to improve the general health. Remedies must 
be exhibited for a long time and, if well selected, without 
change, even if the progress of the case is very slow. The aim 
of medication is to bring about a profound constitutional 
change which shall fortify the child against the serious mischief 
arising from even a slight cold or special liability to fall an 
easy victim to infectious diseases like diphtheria and scarlet 
fever, which thrive best upon structures already weakened by 
previously existing disease. 



DISEASES OF THE CESOPHAGUS. 
OESOPHAGITIS. 

Inflammation of the oesophagus is acute or chronic. It may 
be caused by exposure to cold and damp or by extension of 
catarrhal inflammation from the mouth, pharynx and 
stomach, or from the extension of similar processes occurring 
in the specific fevers. In others it is the result of irritation 
from the use of very hot or very cold drinks or food, irritating 
medicines, strong acids, caustic alkalies, or the long-ccntinued 
excessive exhibition of tartar emetic. It is also seen in connec- 
tion with malignant disease of the oesophagus, as cancer. Oc- 
casionally it appears as a spontaneous affection in sucklings ; 
these cases show a pronounced tendency to ulceration. 

The anatomical character varies with the cause and type of 
the affection. In the common form, slight, if any, redness ex- 
ists, but there is thickness and desquamation of the epithelium, 
swelling of the mucous follicles, and erosion. If due to the ac- 
tion of an irritant, the mucous membrane is bright-red and in- 
flamed. If the inflammation is phlegmonous, there is much 
swelling of the mucous membrane and purulent infiltration, lo- 
calized or diffuse, with gangrene in exceptional cases. Pseudo- 
membranous deposits may be present in connection with diph- 
theria, pyaemia, etc.; these usually involve the upper oesophagus. 



CESOPHAGITIS. 741 

Pustular oesophagitis occurs with small-pox or from the pro- 
longed use of tartar emetic ; if the latter, the lower portion of 
the tube is affected. The pustules may burst, leaving an eroded 
surface. A chronic catarrh of the oesophagus is described in 
connection with the enlargement and varicosis of the tube 
which occurs with senile and cirrhotic liver and with chronic 
heart-disease. 

Symptoms. — Mild forms of oesophagitis commonly escape 
recognition. In more severe cases there is a sense of constrictive 
fulness in the oesophagus, with pain, much aggravated from 
swallowing. This pain may be pressive, lancinating, burning, 
shooting, its character depending largely upon the acuteness of 
the inflammation. In the average case it is not severe. If the 
result of swallowing a violent irritant, it is intense, even ago- 
nizing, and almost always associated with a corresponding 
painful inflammation of the mouth, pharynx and stomach. De- 
glutition in such cases is exceedingly painful, even impossible. 
The food frequently is rejected, and returns covered with mucus, 
blood, pus, or shreds of membranous matter. The patient here 
may complain of dull pain behind the sternum or between the 
scapulae, and there is much sensitiveness to pressure in the 
upper portion of the tube. Dysphagia is worse in the recum- 
bent than in the upright position. Few, if any, constitutional 
symptoms are noted in the average case. If severe, the tongue 
is coated, the breath fetid, and salivation copious. In extreme 
cases the gravity of the constitutional symptoms depends upon 
the severity and character of the primary affection, sometimes 
shock and collapse. 

Cicatricial contraction and stricture are common sequels of 
inflammation due to local action of powerful irritants. 

The diagnosis of mild cases is involved in uncertainty. If due 
to the action of some acid or caustic, the history of the case, as 
well as the pronounced character of the sypmtoms, leads to an 
easy recognition of the trouble. The introduction of the 
sound, and its return covered with blood, pus, membranous or 
necrosed tissue, demonstrates the presence of such tissue- 
changes as result from some form of violent inflammation. 

Treatment. — Since only the severe cases are recognized, it is 
with them only that the physician is liable to deal. If due to 
some foreign body in the gullet, this must be removed or, if 



742 DISEASES OF THE DIGESTIVE ORGANS. 

that cannot be done, forced into the stomach. If some violent 
irritant has been swallowed, the proper antidote (caustic al- 
kali: vinegar and water; acid: dilute alkali drinks) must be 
given at once. Dysphagia suggests the use of nourishing in- 
jections per rectum and bland, demulcent drinks, if they can be 
taken. The external application of ice is recommended. The 
early use of the bougie may assist in preventing stricture. 

Therapeutics. — Arnica. The oesophagus has been bruised by 
the passage of a foreign body. Stinging pain during degluti- 
tion.— Belladonna. Sensation as of "narrowing" in the oesoph- 
agus ; as though a foreign body had lodged in it ; exceedingly 
painful deglutition ; spasmodic contraction of the oesophagus, 
causing regurgitation of food and drink, brought on by every 
attempt to swallow. — Cantharides. Throat feels as though 
on fire ; thirst, with aversion to all fluids ; burns or scalds of 
the oesophagus. — Kali bichromicum. "Burning sensation 
from pharynx or stomach; pain and feeling as though some- 
thing remained in the oesophagus after swallowing solids." — 
Phosphorus. Hale reports two cases caused by Gelsemium, 
cured by Phosphorus, but he gives no indications. — Rhus tox- 
icodendron. Burning and soreness in the oesophagus ; throat 
feels swollen internally ; pricking pain, as if a pin had lodged in 
the throat ; feeling of contraction in the oesophagus ; dysphagia 
with stinging pain during deglutition (Laird). — Veratrum 
viride. Great dryness and heat in the throat ; burning in the 
fauces and oesophagus; spasm of the oesophagus with or with- 
out rising of frothy and bloody mucus. 

STRICTURE OF THE CESOPHAGUS. 

Stricture or stenosis of the oesophagus is congenital or ac- 
quired. The former is very rare; the latter is due to narrowing 
of the gullet by enlargement of the mucous and submucous tis- 
sues, with or without fibrous deposits, but oftener to cicatri- 
cial contraction from the healing of ulcers in the wall of the 
oesophagus, to cancerous growths or polypoid tumors pro- 
jecting into the gullet, or to external pressure from enlarged 
glands, tumors or aneurism. 

The occlusion ma}' occur at any point or may involve the en- 
tire length of the tube ; in exceptional cases several well-defined 



STRICTURE OF THE (ESOPHAGUS. 743 

strictures may exist. The degree of the narrowing differs ; it 
may be inconsiderable or almost amount to a closure. If due 
to cicatrization, the stricture is more likely to be at the upper 
or lower end of the gullet. If high, food is rejected at once or 
very soon ; if low, it accumulates above the point of stricture, 
forcing the walls outward, and is then ejected in larger quan- 
tities; the alkalinity of the food and its freedom from "gas 
trie" odor are important diagnostic points. This retention of 
food in the oesophagus— the stricture preventing its entrance 
into the stomach — necessitates bulging and yielding of the 
oesophageal wall, and eventually brings about an enlargement 
of the gullet above the point of stricture, with hypertrophy of 
the wall. 

Symptoms. — The symptoms of the stricture are increasing 
difficulty of swallowing food, especially in large morsels, until 
at last even liquids cannot enter the stomach. The ineffectual 
attempts to swallow are accompanied by much distress, and 
followed by spasmodic contraction of the gullet, sense of con- 
striction and suffocation in the throat and chest, distress be- 
hind the sternum— sometimes in the stomach — , .palpitation of 
the heart and other nervous disorders. Emaciation, extreme 
in cases where the stricture borders upon occlusion, is a con- 
stant symptom, and starvation eventually results, unless death 
occurs from the severity of local complications (as rupture or 
gangrene) or from the development of some profound consti- 
tutional disease attacking the debilitated and vitiated system 
(tuberculosis). 

The diagnosis usually is easy, because the sypmtoms are 
well-pronounced. Auscultation may be helpful in fixing the 
exact location of the stricture. The patient is directed to fill 
the mouth with water, and is made to swallow after the ear of 
the physician has been placed to the left of the spine. If stenosis 
exists, a splashing, gurgling sound can usually be heard at the 
seat of the stricture. The bougie will verify the site and prove 
the extent of the stricture. The patient is placed in a chair, the 
head well backward. A large bougie is passed into the phar- 
ynx, under the guidance of the index finger of the left hand. 
The bougie, or gum-elastic stomach tube, is then gently slipped 
along the wall of the pharynx, to one side of the median line, 
into the oesophagus. The cricoid cartilage offers some slight 



744 DISEASES OF THE DIGESTIVE ORGANS. 

obstruction, which, however, is readily overcome. An instru- 
ment of large size must be employed, and the manipulation 
conducted patiently and gently lest the tube enter a diverti- 
culum or pass through diseased, softened tissue (cancerous 
ulcer). 

The prognosis must be guarded. Strictures due to the exist- 
ence of cicatricial tissue in the pharynx are, as a rule, amenable 
to proper treatment. If depending upon mechanical pressure, 
the removal of which comes within the reach of surgical science, 
a recovery may be looked for. If due to congenital malforma- 
tion, the prognosis is unfavorable. If from malignant disease, 
a recovery cannot be expected. 

Treatment. — The treatment is almost entirely surgical. 
Remedies can do little mere than aid in controlling special 
symptoms. Belladonna, Ignatia, Conium, Hyoscyamus, 
Natrum muriaticum, Nux vomica, Pulsatilla, and others, 
have been recommended. B. F. Joslin gives the following: 

Belladonna. Sensation as of a lump which cannot be re- 
moved. Impeded deglutition or entire inability to swallow 
even liquids. Short-lasting, but frequently recurring, contrac- 
tion of the oesophagus. When swallowing, one experiences a 
sensation in the throat as though the parts were too narrow, 
contracted, as if nothing would go down. Pressure in the 
throat with choking ascending from the abdomen. — Ignatia. 
Sensation as if one swallows over a lump. Strangulating sen- 
sation in the middle of the fauces, as if a large lump had lodged 
in the throat. Difficulty in swallowing solid or liquid food. — 
Mercurtus. Sensation as if something had lodged in the 
throat. Difficult deglutition. He had to press very hard to get 
something down. Spasmodic difficulty in swallowing, with 
danger of suffocation. Aching pain in the oesophagus. — 
Natrum muriaticum. Sensation as though a plug had lodged 
in the throat. Spasms in the pharynx. When swallowing, she 
found it very difficult to get the food down or bring it up 
again, so that she came near suffocating.— Pulsatilla. Sen- 
sation on swallowing as if the back part of the throat were 
narrower than usual or closed by swelling. Sensation as if the 
pharynx were swollen. When swallowing, he feels as though 
the throat were swollen. Difficult swallowing, as if from par- 
alysis of the muscles of deglutition. Choking pain in the 
pharynx, as from swallowing too large a morsel. 



DILATATION OF THE CESOPHAGUS. 745 

It is safe to add that actual clinical experience with the indi- 
cated remedy alone has not been satisfactory. 

Feeding by means of the stomach tube and per rectum sooner 
or later becomes necessary. 

DILATATION OF THE OESOPHAGUS. 

In very rare cases dilatation may be primary ; almost always 
it follows previous constriction of the oesophagus, as explained 
in the preceding chapter. It may be partial or general. 

A diverticulum consists of an enlargement or pouch in the 
gullet, made by pressure or traction. If by pressure, it is com- 
monly found at the pharyngo-oesophageal juncture, due to the 
comparative weakness of the muscles there, and occurs in shape 
of a saccular pouch. If made by traction, it is more often sit- 
uated at the anterior wall, near the bifurcation of the trachea, 
the gullet being drawn outward by inflammatory adhesion ex- 
tending from the lymph glands. A small diverticulum which 
communicates through a narrow opening with the oesophagus 
rarely gives rise to much trouble; if large, forming a blind 
pouch, it intercepts the passage of food into the stomach and 
may cause stricture. 

Symptoms.— Small diverticula and moderate dilatation do 
not create sufficient disturbance to attract the patient's atten- 
tion. If the dilatation is large, difficulty of swallowing and 
rumination of food are noted. Food frequently is retained for 
a long time, undergoing chemical changes, causing exceedingly 
foul odor from the mouth and terribly offensive breath. 
Eventually the dilatation may be so great as to give rise, by 
pressure upon, the trachea, blood-vessels and nerves, to serious 
embarrassment of respiration, circulation and innervation. If 
the dilatation is in the upper oesophagus, the swelling may be 
detected behind the trachea, remaining there until the detained 
food has been ejected by vomiting or regurgitation, when it 
promptly disappears. 

The symptoms of large diverticula closely resemble those of 
dilatation, save that the regurgitation of food is delayed sev- 
eral hours and the detained mass is even more offensive. 

In either case nutrition soon becomes seriously deranged ; 
emaciation and great weakness follow ; the face looks haggard 



746 DISEASES OF THE DIGESTIVE ORGANS. 

and expressive of severe, habitual suffering. Death takes place 
from perforation of the oesophagus or from starvation. 

The prognosis is decidedly unfavorable. 

Treatment is unsatisfactory and largely mechanical. Inter- 
nal medication can do little more than relieve pain and thus 
prolong life. Common sense suggests the use of liquid food, 
and, in case of diverticula, their administration through the 
stomach tube. 

RUPTURE AND PERFORATION. 

Rupture of the healthy oesophagus has resulted from pro- 
longed violent vomiting; it is exceedingly rare and invariably 
fatal. When the walls of the gullet have been weakened by 
atrophy, or ulceration, or destructive processes, retching and 
vomiting may easily cause rupture, more often at a point just 
above the diaphragm. The rupture may be longitudinal or 
transverse, usually the former. With it, there is escape of the 
contents of the oesophagus into the surrounding connective 
tissues or into the trachea, pericardium, lungs or pleural sac. 

Perforation occurs from within outward from abscess or 
perforation of the gullet, or from injuries to its structures re- 
ceived from foreign bodies; from without inward, as the result 
of pressure upon the oesophagus, as from aneurism of the 
aorta, or of ulceration or destruction involving adjacent tis- 
sues, as tubercular ulceration, retro-pharyngeal abscess, caries 
of vertebrae, etc. 

The symptoms are sudden, sharp pain in the breast, sensa- 
tion of a tear in the gullet, vomiting, coughing, paroxysms of 
choking, orthcpnoea, haemorrhage, shock and collapse. If the 
results are not immediately fatal, purulent or gangrenous in- 
flammation of the injured structures and of the tissues invaded 
by the expelled contents of the oesophagus necessarily follows. 

The diagnosis is positive when these symptoms occur in a per- 
son suffering from disease of the oesophagus. 

The prognosis is bad, save in very exceptional cases when 
the rupture or perforation is so small that it allows of the es- 
cape of only a trifling amount of the contents of the oesopha- 
gus. 

Treatment consists chiefly of absolute rest of the injured 
parts. 



MORBID GROWTHS— CANCER. 747 

Rectal feeding alone is allowable, since the use of the stomach 
pump is obviously dangerous. The relief of thirst is a perplex- 
ing task, and may be in part accomplished by frequent spong- 
ing of the body in tepid water or rinsing of the mouth with 
acidulated drinks, or by holding bits of ice in the mouth. Stim- 
ulants may have to be used hypodermically. If death does not 
take place at once, remedies indicated by the totality of symp- 
toms may be administered as the conditions allow. 

MORBID GROWTHS-CANCER. 

Morbid growths of the oesophagus are benign or malignant. 
The former are rare, and consist chiefly of fibroid polypi. They 
are of slight importance clinically, save that they occasionally 
become a source of irritation and, from their bulk and situa- 
tion, of annoyance. 

Malignant growths are much more frequent. Cancer of the 
oesophagus is not an uncommon disease. The varieties seen are 
the epithelial, medullary, and scirrhous, of which the epithelial 
ranks first in the order of frequency. Ziemssen affirms that 
primary cancer of the gullet is always epithelial. 

Cancer of the oesophagus is usually primary. It begins in 
the submucous tissue and soon involves the mucous membrane. 
Its favorite location is the upper third of the gullet, but it may 
select some other portion, or the entire tube may be affected. 
Its growth is attended with narrowing of the tube (stricture) 
at the seat of the disease, dilatation and hypertrophy above, 
and atrophy and collapse below. Its progress is marked by 
disintegration and sloughing of tissues, with such complica- 
tions as are incidental to cancerous growths elsewhere. There 
may be matastatic deposits in brain, kidney, lungs, and liver, 
or invasion of adjacent organs, as the viscera of the thorax. 
Perforation eventually takes place into the lung, trachea, 
bronchus or mediastinum, or destruction of the walls of blood- 
vessels (aorta) may occur, or even adjacent osseous tissues 
(vertebras) may become involved. 

Symptoms.— It is not often possible to recognize this disease 
until after there has been dysphagia and pain in the oesopha- 
gus— at first rather a vague distress— with possible loss of flesh. 
The difficulty of swallowing increases, and there is regurgita- 



748 DISEASES OF THE DIGESTIVE ORGANS. 

tion of food recurring within a short time after swallowing if 
the upper third of the gullet is the seat of the cancer ; this is de- 
ferred for ten or fifteen minutes, or longer, if the growth is situ- 
ated near the stomach. The regurgitated mass contains 
mucus, blood, shreds and fragments of cancerous tissue, ac- 
cording to the stage of the disease. Violent tearing, pricking, 
burning pain, often extending upward, again into the stomach 
or towards the shoulders and spine, maj^ be the cause of much 
suffering; in other and rare cases pain is practically absent. 
Difficult, weak speech, sometimes aphonia, and dyspnoea may 
result from pressure of the growth upon the recurrent laryn- 
geal nerve and upon the larynx and trachea. As swallowing 
becomes more and more difficult and painful, emaciation be- 
comes correspondingly pronounced. Enlargement of the cer- 
vical lymph-glands is frequently seen, often even in the early 
stage of the disease. The constitutional symptoms of the can- 
cerous cachexia, when fully developed, are easily recognized. 
Death eventually takes place from perforation, haemorrhage or 
marasmus. 

The diagnosis of cancer of the oesophagus depends upon the 
severity of the pain, the gravity of the characteristic constitu- 
tional symptoms, the presence of a cachexia, and the recogni- 
tion, under the microscope, of the cancer cell. "In persons over 
fifty years of age persistent difficulty of swallowing accompa- 
nied by rapid emaciation usually indicates oesophageal cancer" 
(Osier). 

Pains must be taken to exclude, by careful laryngoscopy and 
other examination, especial^ in the early stage, aneurism, 
benign growths, and stricture. 

The prognosis is hopeless. 

Treatment. — The treatment is largely surgical. Benign 
growths can usually be removed. In malignant disease the aim 
is to prolong life and to make it endurable, a cure being out of 
question. 

The diet must be nourishing and will usually consist of liquid 
food, as milk, broths, etc. The stomach tube will be useful 
until ulceration has been established, when it must be put aside, 
and food be administered per rectum. Medication has accom- 
plished no positive results. Arsenicum album, Arsenicum 
iodatum, Lachesis, Hydrastis and Conium are more likely 



THE NEUROSES OF THE CESOPHAGUS. 749 

than others to ameliorate the pain and retard the progress of 
the disease. 



THE NEUROSES OF THE CESOPHAGUS. 

Sensory derangements affecting the oesophagus are little un- 
derstood and rarely recognized. Motor derangements have 
been studied more successfully ; they may be divided into Spas- 
modic Stricture and Paralysis. Spasmodic Stricture, GBsopha- 
gismus or CEsophagospasmus may be idiopathic or sympto- 
matic. In the former no definite anatomical lesion exists to ac- 
count for the occurrence of the spasm of the gullet ; in the lat- 
ter a specific cause for the irritation may be assigned. 

In the majority of cases the patient is of a decidedly neurotic 
temperament and presents clear-cut symptoms of functional 
nervous disease. Women, especially at those periods of life 
which involve a special strain upon the nervous system, as 
pregnancy and the menopause, or young girls at the age of 
puberty, furnish many cases. Men are not exempt. Elderly 
men, afflicted usually with hypochondriasis, suffer from oeso- 
phageal spasm. The writer has seen several cases in young 
boys of an inherited neurotic tendency which had been inten- 
sified by false living and further irritation of the enfeebled ner- 
vous system by masturbation. Cases are also noticed in con- 
nection with epilepsy, chorea, hysteria, hydrophobia. 

At times the affection is due to local irritation, such as a mild 
inflammation of the tube, or the pressure in the gullet of some 
foreign body or of a morbid growth, as an aneurism ; or to 
irritation of a nerve, as the peripheral branch of the pneumo- 
gastric. Again, it may be reflex in character, as in cases of in- 
testinal irritation from worms, constriction at the anus, haem- 
orrhoids, or gastric, uterine or ovarian disease. In all these 
conditions, however, the existence of a neurotic temperament is 
an important factor, and commonly some powerful emotional 
disturbance is responsible for the first appearance of the spasm. 
Occasionally, the habit once established, the affection be- 
comes very distressing because the spasms appear from trifling 
causes and are slow to yield to treatment. 

Symptoms. — Sudden difficulty of swallowing food is the most 
important and characteristic symptom, generally associated 



750 DISEASES OF THE DIGESTIVE ORGANS. 

with more or less substernal pain, hiccough, difficult breathing 
and excessive nervousness, often with the fixed conviction that 
death from choking is imminent. In many cases marked excite- 
ment is present. If the spasm affects the upper third of the 
tube, food or drink is rejected almost at once ; if near the car- 
diac portion, it is retained for some time, to be returned mixed 
with mucus and occasionally slight traces of blood. In stub- 
born cases dilatation of the gullet above the seat of the strict- 
ure may occur, with retention of food for a considerable time. 
Liquids are more easily swallowed than solids, though the re- 
verse may obtain. The paroxysm usually is of brief duration, 
but in aggravated cases may be so persistent— lasting for days 
—that it causes much concern. The spasms recur periodically 
or at irregular intervals. If persistent, the general condition of 
irritability of the nervous system from weakness increases and 
is intensified by the insufficient nutrition of the body. In many 
cases the disappearance of the spasm, as in other seizures of a 
hysterical character, is followed by copious emissions of flatus 
and of watery, limpid urine. 

Diagnosis. — The totality of the S3^mptoms in so many cases 
clearly expresses the neurotic element at work that it at once 
places the physician on his guard. The suddenness with which 
the d^^sphagia appears is striking, but not of much diagnostic 
value since the same occurs in connection with cancer. The 
intermittency of the paroxysms is, however, of much import- 
ance. The introduction of the bougie is rarely difficult of ac- 
complishment here, and almost always affords relief ; in some 
instances it even appears to effect a cure. 

The prognosis is good. Fatal cases are very exceptional. 

The duration of the disease varies, some cases yielding 
promptly, while others continue for an indefinite period of time. 

Treatment.— The treatment includes the use of the sound, 
which, as stated, may actually cure. It is not necessary to 
point out that great care must be exercised in the use of the 
sound to avoid serious or even fatal accidents by rupturing 
the wall of a tube weakened by inflammation or ulceration, or 
by forcing the instrument into an aneurism or cancerous mass. 

Electricity has proved serviceable. Rockwell advises, for 
their constitutional tonic effects, both general faradization and 
central galvanization as "more successful than anything else." 



THE NEUROSES OF THE OESOPHAGUS. 751 

Locally he urges the use of the galvanic current. "One pole 
(cathode) may be placed upon the back of the neck, over the 
cilio-spinal center, while the anode is held just above the ster- 
num, or by the inner border of the sterno-cleido-mastoid mus- 
cle. If this fail, an insulated oesophageal electrode with a me- 
tallic tip should be introduced into the oesophagus to the point 
of spasm, while the other is placed on the bacK of the neck. 
Both currents can be used in this way, but special caution is to 
be exercised in the application of the galvanic current, on ac- 
count of the proximity to the pneumo-gastric. It is not incon- 
ceivable that over-excitation of these nerves might be attended 
with serious results. The galvano-cautery has sometimes 
proved a most effective procedure in these cases after the failure 
of the ordinary electrical applications" (International System 
of Electro-Therapeutics). 

Diet must be nourishing, chiefly liquid, and, if necessary, 
given by means of a tube. 

The internal use of properly indicated remedies is usually sat- 
isfactory here ; in many cases, by virtue of their relation to the 
morbid conditions primarily at fault, they accomplish much 
more than any other measure. The following are specially ser- 
viceable: Asa fcetida. In nervous, hysterical people, with men- 
tal and physical hypersensitiveness. Sensation in the oesopha- 
gus as if peristaltic action were reversed, proceeding from below 
upward, obliging him to swallow frequently. Food, when par- 
tially swallowed, returns to the mouth. Gastric flatulency, 
causing distress in the stomach and about the heart, with 
choking sensation in the throat and great anxiety. — Baptisia. 
It has well-marked "inability to swallow solids;" cannot 
swallow anything but liquids. Constriction of the oesophagus 
from the pharynx to the stomach. Its clinical record in this 
affection is good.— Belladonna. Violent and spasmodic con- 
traction of the oesophagus, causing the food to be expelled. 
Sensation of narrowness of the parts, of constriction. Spasms 
brought on by every attempt at swallowing, yet constant de- 
sire to swallow. Foreign bodies in the throat.— Cocculus. 
Burning dryness of the oesophagus. Taste of sulphur in the 
mouth. The local symptoms are not strongly characteristic, 
but the remedy is of great value when spasm of the gullet 
exists in choreic or epileptic persons, with a tendency to par- 



752 DISEASES OF THE DIGESTIVE ORGANS. 

alysis. There is hyperesthesia, insomnia, and a general state 
of "weakness from irritability" of the nervous system. Aggra- 
vations during menstruation, with headache and vertigo, faint- 
ness and goneness, mental dulness and hypochondriasis. — Cro- 
talus. Great muscular weakness and trembling. Chronic 
spasms of the oesophagus, occurring in connection with atonic 
dyspepsia, "with continual throbbing, occipital headache, 
trembling, fluttering feeling below the hypogastrium, towards 
the umbilicus; tongue very red and small, feet swollen." Dys- 
menorrhoea. The throat is very sensitive; cannot swallow 
anything solid ; even soup must be strained to remove from it 
all meat fibres and solid particles. Pain out of proportion to 
the visible trouble. — Hydrocyanic acid. Spasm in pharynx 
and oesophagus, with heat, inflammation, and inability to 
swallow. Like Cocculus, the local indications are overshad- 
owed by the constitutional symptoms. It is particularly use- 
ful in cases of irritability resulting in tetanic contraction of 
muscular fibre, especially in hysterical subjects. Faintness, 
goneness at the stomach, coldness of skin and of extremities, 
feeble and irregular action of the heart. Chronic dyspepsia, 
with vomiting of food in the evening and at night. Gurgling 
noise in the throat when swallowing a drink. — Hyoscyamus. 
Can swallow warm solid food better than liquids. Tendency 
to hysteria, epilepsy and nervous diseases characterized by con- 
vulsive action. Violent and demonstrative. Convulsive, ner- 
vous ccugh. — Ignatia. In hysterical cases, with irritability of 
muscular fibre, characteristic mental sj^mptoms (quiet grief and 
despondency ; alternate laughing and crying) ; empty, gone, 
faint feeling at the stomach, better from taking food; excessive 
flatulency, with palpitation of the heart; nervous cough which 
can be suppressed by a strong effort of will, and grows worse 
as the patient yields to the desire to cough ; sympathetic 
cough, with uterine or ovarian troubles or from intestinal irri- 
tation (worms). Spasms of oesophagus from mechanical irri- 
tation. — Lachesis. Hysterical condition, especially when char- 
acterized by insane jealousy. Characteristic sensitiveness of 
the throat to touch ; fluids return through the nose ; aggrava- 
tion upon waking from sleep. — Naja tripudians. "Spasmodic 
stricture of the oesophagus ; hardly anything can pass into the 
stomach ; laryngismus from spinal irritation affecting nucha" 



THE NEUROSES OF THE CESOPHAGUS. 753 

(Lilienthal).— Phosphorus. Great exhaustion and irritability 
of the nervous system. Drink and food vomited up soon after 
it has reached the stomach. Characteristic gastric affections. 
Not often indicated, but none the less important because of its 
relation to profound primary disturbances. — Plumbum. Useful 
on account of its profound action on the brain and nervous 
system. Restlessness; hyperesthesia ; convulsions; epilepsy; 
paralytic tendency, with trembling of the extremities from 
slight exertion or from excitement. Sensation as of a ball ris- 
ing from the throat into the head ; paralytic condition of the 
pharyngeal muscles, with difficult swallowing of liquids. Se- 
vere spasms of the sphincter ani in connection with constipa- 
tion and haemorrhoids. — Stramonium. Violent contraction of 
the throat ; deglutition is almost impossible ; terrible spasm of 
the throat when attempting to swallow ; hysteria, with con- 
vulsive excitement, from fright. Hysterical hydrophobia. — 
Yeratrum yiride. Hysterical and epileptiform convulsions. 
Acute inflammation of the oesophagus, with fiery, burning 
pain. Spasm of the oesophagus with or without rising of 
frothy, bloody mucus. 

Consult also Alumina, Bryonia, Cicuta, Elaps, Kali car- 
bonicum, Laurocerasus, Natrum muriaticum, Pulsatilla. 

Paralysis of the oesophagus may be partial or complete, and 
is almost always of central (bulbar) origin. The practitioner 
sees it in connection with paralysis of the tongue, palate, phar- 
ynx or larynx, or as a feature of general paralysis Inability 
to swallow is its most conspicuous symptom. Large mouth- 
fuls of food are usually more easily swallowed than smaller 
morsels, and solids easier than liquids. There is no obstruction 
to the passage of the sound. 

The prognosis is unfavorable. 

Treatment is unsatisfactory. Electricity, so far, has given 
slight and temporary results only in exceptional cases. Of 
remedies, Cocculus, Plumbum, Gelsemium and Phosphorus 
are the most promising. The selection of the remedy involves 
an exhaustive study of the totality of symptoms, and in the 
course of such a study clear indications may be found for the 
exhibition of remedies which are not suggested by the local 
affection. The administration of food requires great care in 
advanced cases. The stomach tube and, later, rectal feeding 
are indispensable. 
48 



754 DISEASES OF THE DIGESTIVE ORGANS. 



DISEASES OF THE STOMACH. 

ACUTE GASTRIC CATARRH. 

Acute gastric catarrh, acute gastritis, acute dyspepsia or 
gastric fever, is a common affection. The term acute gastritis 
or acute gastric catarrh is used in a broad sense, practically 
embracing the entire range from a slight, transient ailment to 
a severe, destructive inflammation. The common, light form is 
generally known as acute indigestion. 

Acute catarrh occurs in all climates and at all ages, perhaps 
with a preference for the quite young and the old. It is almost 
always caused by some error in diet, such as over-eating or the 
use of unwholesome food. Not being properly digested, such 
food undergoes partial decomposition in the stomach and be- 
comes a source of irritation. Persons who naturally have a 
"weak," irritable stomach cannot digest what to others is a 
moderate and wholesome meal, both in quantity and quality ; 
thus, idiosyncrasy- and predisposition are important aetiolog- 
ical factors. 

Whatever unduly irritates the gastric mucous membrane is 
liable to cause gastric catarrh. Hence the evil effect of power- 
ful drugs and especially of alcohol upon the stomach. Gastric 
catarrh occurs also in connection with infectious fevers (scarlet 
fever, measles, small-pox, typhoid fever, etc.) and, occasion- 
ally, as the result of metastasis in gout or acute rheumatism. 

Morbid Anatomy. — The pathological condition is a hyper- 
emia of the gastric mucosa, of varying degree and extent. The 
mucous and peptic cells become filled with granular matter 
and fat globules ; the mucous membrane assumes a puffed and 
swollen condition, preventing the discharge of the gastric juices 
into the stomach. The surface of the stomach is covered with 
tenacious mucus of alkaline reaction. Extravasation of blood- 
corpuscles, both red and white, often takes place. In severe 
cases the epithelial covering may be destroyed. Erosions and 
slight haemorrhages often occur. 

In very severe cases septic and gangrenous inflammation may 
result, with extensive sloughing and considerable bleeding. 



ACUTE GASTRIC CATARRH. 755 

Symptoms.— The light form of acute indigestion consists of 
little more than a sense of discomfort or pain in the stomach 
which appears within a few hours after committing some error 
of diet, accompanied with a sense of indisposition, headache, 
nausea, eructations and vomiting. The latter, in these light 
cases, is rarely very severe or painful, and the prompt expul- 
sion of the offending substance affords ready relief. The 
ejected matter consists of mucus, food and slight admixture of 
bile. There is some coating of the tongue and fever. A few di- 
arrhceic stools may be had, especially in children. Recovery 
takes place quickly, probably within twenty-four hours. In 
some cases even slight attacks are accompanied with "sick" 
headache. 

If the case is rather more aggravated, copious evacuations 
from the bowels take place, and are followed by relief. Should 
the bowels, however, be constipated, the gastric disturbance is 
liable to continue. The tongue is then covered with a heavy 
white or yellowish fur ; the breath becomes offensive; spells of 
vomiting occur at brief intervals, and there is persistent 
frontal or occipital headache. The patient appears nervous 
and fretful ; short spells of shivering alternate with fever and 
a moderate elevation of temperature. After a time the patient 
grows drowsy and enjoys a long, heavy sleep from which he 
awakens refreshed and nearly well. 

In still other cases the gastric symptoms, especially the vom- 
iting, are sufficiently pronounced to cause much distress. Pain 
in the stomach is severe, of a dull, heavy, aching character, 
sometimes a feeling as of a stone or heavy load in the stomach. 
It may be associated with gnawing and f aintness. The tongue 
is heavily furred ; there is frequent vomiting of sour and bitter 
mucus and bile, belching of foul-tasting gas, having the odor 
of sulphuretted hydrogen, with shivering, fever, unrefreshing, 
anxious sleep, and scanty discharges of urine of dark color and 
rich in urates. The abdomen may be distended and somewhat 
tender to pressure. This condition continues for two or three 
days, followed by an uneventful recovery. 

A slight looseness of the bowels is common and desirable ; 
cases where constipation exists are more liable to be severe and 
usually get well slower. 

Subacute gastritis, still called gastric fever by some writers, 



756 DISEASES OF THE DIGESTIVE ORGANS. 

consists of the same grouping of symptoms, but more intense 
and unyielding in character. Chills of some severity take the 
place of the shiverings; these are followed with a temperature 
of 100° to 102°, sometimes with pronounced evening exacerba- 
tions. Pain in the epigastric region may or may not be present ; 
if present, it is dull, sometimes sharp, pressive, radiating into 
the chest, back and hypochondria. There is loss of appetite, 
but occasionally craving for food, which is chiefly due to the 
gnawing and f aintness at the stomach. The patient is thirsty, 
but eating and drinking gives rise to distress and vomiting. 
The latter often is very persistent, easily provoked and painful ; 
the ejected matter consists of glairy mucus, mixed with water, 
food, bile and possibly tinges of blood. The tongue, at first 
thickly furred, becomes red, raw, even fissured, with enlarged 
red papillae. The lips are sore and covered with fever blisters. 
Gastric and intestinal flatulency with emissions of foul gas and 
considerable uneasiness may be present, and there often is 
much epigastric and abdominal distension, with tenderness and 
soreness upon pressure. Prostration, headache, dizziness and 
restlessness, with unrefreshing, disturbed sleep, add to the pa- 
tient's discomfort. This form of gastric catarrh runs a course 
of from a week to ten days. 

Acute gastric catarrh of infants occurs during the heated 
term, chiefly in bottle-fed, badly nourished children, and is a 
more serious disease than the forms already described. The 
symptoms are sudden and violent at the start. Frequent, if 
not constant, vomiting of curdled milk occurs, sometimes of 
sour, watery mucus mixed with curdled milk, accompanied 
with great pain in the stomach. The gastric irritability is pro- 
nounced, food and drink being ejected as soon as swallowed, 
with manifestation of much suffering. There usually is ab- 
dominal tenderness. Soon active diarrhoea of a watery, copi- 
ous, exhausting character sets in, with great prostration, rapid 
emaciation, and a train of symptoms which may terminate in 
cerebral disease, coma and death. 

The gastric catarrh of drunkards is slow in development, but 
exceedingly persistent. Its most marked symptoms are pro- 
found anorexia, and habitually and heavily coated tongue and 
thirst. 

Toxic gastritis is due to the action of some powerful irritant 



ACUTE GASTRIC CATARRH. 757 

upon the stomach, as concentrated mineral acids, alkalies, or 
large doses of arsenic, phosphorus or antimony. There is 
violent inflammation of the gastric mucous membrane and un- 
derlying structures, with intense pain in the mouth, throat and 
stomach; great difficulty of swallowing; constant painful 
vomiting of glairy, stringy mucus, containing blood and shreds 
of mucous membrane ; intense thirst with immediate aggrava- 
tion of vomiting from drinking. The tongue is dry and glazed ; 
there is profound prostration, with coldness of the extremities, 
weak and irregular pulse, difficult breathing, and pale, haggard 
countenance, expressive of anxiety and keen suffering. Diar- 
rhoea of watery, bloody stools with colic and tenesmus proves 
the extension of the inflammation to the intestine. The entire 
abdomen is distended, tender and sensitive to even slight pres- 
sure. The urine becomes scanty, albuminous, even suppressed. 
Symptoms of collapse declare themselves. The vomit assumes 
a coffee-ground color, and death results from haemorrhage or 
collapse. If the termination of the case is not immediately 
fatal, ulceration is likely to occur, resulting in oesophageal 
stricture, chronic hypertrophy of the stomach, and death from 
exhaustion. 

Still other forms of acute gastritis are described, but these 
are difficult of recognition, at least during life, and of slight 
importance to the practitioner. Here belongs the diphtheritic 
or membranous form, which occurs in diphtheria or as a sec- 
ondary affection following typhus or typhoid fever, pneumo- 
nia, small-pox, etc. Acute suppurative or phlegmonous gas- 
tritis consists of suppuration in the submucous tissues ; it is ex- 
ceedingly rare, and may be idiopathic or appear as an expres- 
sion of sepsis (puerperal fever) or as the result of trauma. It 
has not been recognized ante mortem. Gastritis due to the 
presence of parasites, larvas of insects, specific organisms, as 
the bacillus gastricus of Klebs, have been described, but are of 
interest only because of the infrequency with which they occur 
and the difficulty of recognizing them. 

Diagnosis.— The diagnosis is rarely difficult. The knowledge 
that the early stage of infectious fevers often presents sim- 
ilar symptoms suggests the wisdom of being guarded in ex- 
pressing an opinion. When the fever is comparatively high, 
acute gastric catarrh may bear a close resemblance to abortive 



758 DISEASES OF THE DIGESTIVE ORGANS. 

forms of typhoid fever. The absence, in the former, of bron- 
chial irritation and cough, of splenic enlargement and of rose 
spots, with the character of the fever itself — abrupt rise, slight 
remissions, sudden drop— will establish the diagnosis. From 
cardialgia gastric catarrh is distinguished by the steadiness of 
the pain, the irritability of the stomach, its refusal to retain 
food or drink, and the probability of intestinal irritation as ex- 
pressed by intestinal flatulence, abdominal distension and ten- 
derness and, often, diarrhoea. 

Toxic gastritis. The history of accidental or deliberate 
poisoning is almost always clear. The action of the poison 
upon the mouth and throat is intense and may be seen. The 
attack comes on suddenly, the symptoms are severe from the 
very beginning, and there is a tendency to a rapidly fatal ter- 
mination. 

The prognosis is favorable, except in cases occurring in young 
infants, where it must be guarded on account of possible exten- 
sion of the inflammation to other parts and the complications 
which so readily arise. Toxic gastritis is almost always fatal. 

Treatment.— In mild cases medical treatment is practically 
unnecessary. Bicarbonate of soda, dissolved in water, is help- 
ful when there are eructations of acid fluid. Abstinence from 
food for a short time is invariably to be encouraged. Attempts 
to stop vomiting, save as it is controlled by the indicated rem- 
edy, may be set down as worse than useless. 

In severe forms, copious draughts of hot water ease the dis- 
tress of vomiting and greatly lessen the pain in the stomach. 
In the average case, absolute rest of the stomach is of the 
greatest importance, and must be insisted upon if the patient 
is liable to recurrence of the attacks. The return of a natural 
desire for food is an indication that the patient may eat, at 
first cautiously, of simple and easily digested substances. Milk, 
diluted with lime-water or scda-water, then oat-meal gruel, 
and later meat-broths, especially mutton-broth from which the 
fat has been carefully removed, constitute a safe diet for the 
period immediately following an attack. Occasionally a crav- 
ing exists for cold food, and experience has shown that it may 
be gratified within the limits cf good sense ; small draughts of 
cold milk and ice-cream in small amounts, allowed to dissolve 
in the mouth before it is swallowed, are grateful and unobjec- 
tionable. 



ACUTE GASTRIC CATARRH. 759 

If pain and tenderness are severe, hot poultices (linseed meal) 
or hot fomentations (water or infusion of the flowers of hops) 
may be used. If vomiting is excessive, bits of ice in the mouth, 
iced Vichy or iced Champagne, cautiously given, may afford re- 
lief. 

The use of luke-warm water, taken persistently in large 
amounts, a glassful at a time, will aid in removing from the 
stomach the cause of the irritation, and thus serve an excellent 
purpose. Opiates and stimulants are not indicated, save very 
exceptionally. 

In the acute gastric catarrh of infants, absolute rest of the 
stomach is quite as important as in adults. It is folly to pour 
into the irritated organ under the guise of food that which 
is bound to become an additional source of irritation and dis- 
tress. If feeding is absolutely necessary, and rectal alimenta- 
tion is objectionable or unsatisfactory, thin oat-meal or barley 
gruel, carefully strained, or small amounts of mutton broth, 
wholly free from fat, are rather safer than milk. Thirst may 
be relieved by the free use of warm water. 

Therapeutics. — The remedies usually indicated are: Aconite, 
Antimonium crudum, Arsenic, Belladonna, Bryonia, Cheli- 
donium, Hydrastis, Ipecacuanha, Iris, Nux vomica, Phos- 
phorus. Pulsatilla, Podophyllum, Veratrum album, and 
Bismuth. 

Aconite. After taking cold. Stitch-like, burning, pressive 
pain at the pit of the stomach, with anguish and fear of death. 
Quick, hard pulse, with pungent heat of the flesh, and con- 
stant restlessness and tumbling about in bed. Fever with 
great thirst and vomiting of mucus and bilious matter. — Anti- 
monium crudum. Total loss of appetite. Tongue coated 
thickly yellow or white, as though covered with skimmed milk. 
Great thirst at night, nausea, belching, with taste of the food 
that has been eaten. Vomiting. No fever. Useful in saburral 
derangements; after use of sour, spoiled wine.— Arsenic. Gas- 
tric catarrh from the abuse of iced drinks or foods ; also from 
the abuse of tobacco, especially of chewing tobacco. Nausea 
^nd vomiting, worse from rising ; burning pain in the stomach 
and abdomen ; quick, light pulse; dryness of the skin, which 
may be hot or cold ; tongue dry and red, with sides furred, with 
red streak down in the middle ; great thirst, restlessness and 



760 DISEASES OF THE DIGESTIVE ORGANS. 

anxiety, prostration ; watery, thin, dark diarrhoea, very offen- 
sive. Anxious, pale, hippocratic face. Feeling of heavy load or 
stone in the stomach. — Belladonna. Pain in the stomach 
acute, pressive, extending to chest and shoulders; great disten- 
sion and bloating in the pit of the stomach and abdomen, 
worse from motion and pressure, and rendering breathing op- 
pressive ; deficient breathing, anguish, vomiting, gagging, hic- 
coughing ; great thirst, with aggravation from drinking; 
tongue dry and furred or covered with white, tenacious, yellow- 
white mucus. Congestive type. — Bismuth. Burning in pit of 
the stomach ; gagging, vomiting of bile, provoked from even 
slight motion. Gastric flatulency ; cadaverous, offensive diar- 
rhoea.— Bryonia. Stitching pain in the stomach, worse from 
motion ; tongue coated whitish or dark yellow-brown ; dryness 
of mouth and lips, without thirst; or intense, constant thirst 
for large amounts of water. Constipation ; the stools are dry 
and look as though burnt; flatulency. Especially useful in hot 
weather, when the gastric irritation is the result of taking 
cold drinks when heated.— Chelidontum. Biliousness. Nausea, 
bilious vomiting. Tongue is slimy, coated white or gray ; 
heavy yellow coating of the tongue, with red margins, showing 
the imprints of the teeth. Tearing, darting, throbbing head- 
ache, in the forehead and temples, with heaviness and coldness 
in the occiput, accompanied with vomiting, melancholy, 
anxiety. — Hydrastis. Dull, aching pain in the stomach, caus- 
ing weakness and f aintness in the pit of the stomach ; sensation 
of heaviness in the stomach. Tongue coated white or with yel- 
low stripe; feels as if burnt or scalded ; on the tip of the tongue, 
a vesicle which is very sore. Acidity ; constipation.— Ipecacu- 
anha. Constant sickness at the stomach; easy vomiting; 
empty eructations and copious accumulation of saliva ; great 
bloating of the stomach ; pain in the anterior abdomen, extend- 
ing to the left hypochondric region, and upward ; headache as 
if the skull were bruised ; diarrhoea, with much griping, green, 
dark ; tongue flabby, clean, yellow or white. Especially useful 
after eating unripe fruit.— Iris. Intolerable burning distress in 
the stomach ; short spells of colic ; pain in the epigastrium ; 
streaks of pain radiating from the umbilical region into the 
epigastrium; nausea, straining, belching of wind ; vomiting of 
mucus and bile, with diarrhoea, accompanied with burning in 



CHRONIC GASTRIC CATARRH. 761 

the anus and great prostration ; burning in the mouth, fauces 
and oesophagus. Sick headache.— Nux vomica. Sour, bitter 
taste in the mouth. Tongue coated white or yellow. Fulness 
and dull, heavy pressure in the stomach. Dizziness with severe 
frontal headache and irritability of temper. Worse in the 
morning, in the open air, after eating. — Phosphorus. Acute, 
burning pain in the pit of the stomach ; soreness in the region 
of the stomach; shivering; cramp in the stomach, radiating 
from the liver; vomiting of watery substances, at times mixed 
with blood; great thirst for cold drinks which are not retained 
in the stomach after they get warm; tongue dry, coated white. 
— Pulsatilla. No appetite; no thirst; tongue coated white 
or yellow, with tenacious mucus; edges feel as if scalded ; 
mouth parched and dry, still wants nothing to drink ; bitter 
taste in the mouth and of everything he eats ; dizziness when 
arising from a chair ; chilliness ; stitching pain in the stomach, 
worse from motion or from a jar ; perceptible pulsations in the 
stomach ; tension in epigastric region, extending upward. At- 
tack brought on by the injudicious use of ice-cream, fruit, rich 
pastry. — Podophyllum. Everything in the stomach turns 
sour ; belching of sour, hot flatus, with great thirst and sour, 
bitter vomiting, preceded by distressing nausea and accompa- 
nied with such violent contractions of the stomach that the pa- 
tient screams with pain; vomiting of bilious matter, mucus and 
blood; tongue furred, white, dry, yellow; foul taste in the 
mouth.— Veratrum album. Violent vomiting, with constant 
nausea ; utter prostration ; pains radiate from the stomach up- 
ward and to both sides and to the back between the scapulae ; 
it becomes agonizing and then gradually subsides ; coldness, 
fainting ; hippocratic face ; watery, gushing diarrhoea ; cannot 
bear the slightest motion, for it brings on immediate aggrava- 
tions; tongue cold, covered white, with red tip and edges or 
coated yellowish-brown. 



CHRONIC GASTRIC CATARRH. 

Chronic gastritis, chronic gastric catarrh, chronic dyspepsia, 
is a disorder of the stomach characterized by certain structural 
alterations in the gastric mucous membrane and by weakness 



762 DISEASES OF THE DIGESTIVE ORGANS. 

of the muscular coats of the stomach, giving rise to increased 
flow of gastric mucus, changes in the gastric juices, and feeble- 
ness of the digestive movements, resulting in derangements of 
appetite, digestion and nutrition, uneasiness and tenderness in 
the epigastrium, slight fever, and general physical and mental 
depression. 

Etiology.— Chronic gastric catarrh is an affection, chiefly, of 
middle age (from forty to sixt^^ years of age) ; it occurs some- 
what more frequently in men than in women, predisposition 
and inherited tendency playing an important part. Conditions 
which cause the acute form of gastric catarrh may also give 
rise to the chronic form, and many cases of the latter result 
directry from imperfect recovery from acute gastritis. What- 
ever weakens the integrity of the stomach must be considered 
a predisposing cause. 

Among the exciting causes the most prolific are: errors of diet, 
either excessive eating or the use of unsuitable articles of diet ; 
improper mastication of food from hurried eating or from bad 
teeth ; drinking too freely at the table, especially ice-water ; the 
excessive use of spices, tea, coffee, intemperate use of tobacco or 
alcoholic drinks ; the long-continued exhibition of certain drugs 
(arsenic, iron, cubebs, mercury) irritates the stomach and is 
productive of gastritis. The affection occurs in connection 
with organic disease of the stomach (ulceration, cancer), wast- 
ing diseases (as phthisis) and affections which disturb the 
portal and abdominal circulation (diseases of the liver, espe- 
cially cirrhosis) ; also in gout, albuminuria, chronic heart- 
disease, anasmia, chlorosis. 

Morbid Anatomy. — The gastric mucous membrane undergoes 
histological changes which show "the picture of a parenchy- 
matous and interstitial inflammation. The gland cells are in 
part eroded or show cloudy glandular swelling or atrophy. 
The distinction between the principal and marginal cells can- 
not be recognized, and in many places, particularly in the 
pyloric region, the tubes have lost their regular form and show 
in many places an at} r pical branching like the finger of a glove. 
Individual glands are cut off toward the fundus, but appear at 
the border of the submucosa as cj^sts, partly empt} T , with a 
smooth membrane, partly filled with remnants of hyaline and 
refractile epithelium. An abundant small-celled infiltration 



CHRONIC GASTRIC CATARRH. 763 

presses against the tubules and is particularly marked toward 
the surface of the mucosa, and from the sub-mucosa extensions 
of the connective tissue may be seen passing between the 
glands. The mucoid transformation of the cells of the 
tubules is a striking feature in the process, and may ex- 
tend to the very fundus of the glands" (Ewald). 
Atrophy of the glandular structure and of the mucous mem- 
brane itself (sclerotic gastritis) may take place, one form 
(phthisis ventriculi) with thinning, the other (cirrhosis ven- 
triculi) with great thickening, of the coats of the 
stomach. In the former the size of the stomach is not ma- 
terially affected, while in the latter it is much reduced. 

Symptoms. — The symptoms are those of indigestion, with 
sense of fulness and oppression soon after eating, occasionally 
severe enough to be designated a "pain." Sometimes a similar 
distress is experienced when the stomach is empty. Bloating 
in the epigastric region results from retarded digestion, which 
is due to lack of muscular energy of the stomach and alkalinity 
of the gastric juices ; the gas thus formed causes distress, eruc- 
tations of gas, followed by temporary relief, nausea, and even 
vomiting. With these eructations of gas, mouthfuls of partly 
digested food may be brought up, and "watery, sour, rancid 
fluid, so irritating as to give rise to a severe burning pain in 
the substernal region (heartburn). The degree of pain experi- 
enced varies from a vague distressing sensation and fulness or 
soreness to touch to, occasionally, intense suffering. It is often 
associated with a sense of emptiness, of extreme "goneness" or 
faintness at the stomach. Vomiting in the average case is not 
persistent, but is quite common an hour, or two, after eating. 
Sometimes it recurs with considerable regularity every few 
days. In patients suffering from chronic alcoholism, phthisis 
or albuminuria it is frequent and annoying, the ejected matter 
consisting of stringy, glairy mucus in large amounts, often 
with an admixture of blood. In common cases the vomited 
matter consists of food in various stages of digestion, and 
slimy mucus, hydrochloric acid being present in abnormally 
small quantity. The appetite is fitful, unreliable ; the patient 
may eat a few mouthfuls or nothing, or he may take food 
freely and suffer correspondingly. The tongue is large, flabby, 
coated white and shows the indentations from the teeth ; or it 



764 DISEASES OF THE DIGESTIVE ORGANS. 

may be red, with prominent papilla? and pointed tip; or, if 
"bilious," of brownish-yellow. The breath is offensive, and 
there is much complaint of foul taste in the mouth. Catarrh of 
the pharynx, with tough, tenacious, foul mucus in the throat 
and hacking cough, is common. The bowels, usually, are con- 
stipated, and the patient suffers from flatulency, colic, dull 
headache and hemorrhoidal troubles ; in other cases, diar- 
rhoea of a watery character and much flatulenc\ T prevails. The 
urine is alkaline, often cloudy when first voided, iridescent 
upon standing; its specific gravity is increased, and there is a 
hea\w sediment of urates ; oxalates and earthy phosphates are 
also present. Jaundice may result from duodenal catarrh. 
Malnutrition eventually results, giving rise to physical weak- 
ness, mental depression, peevishness and irritability. The 
pulse is slow and regular, except as the action of the heart is 
disturbed by the gastric flatulency. There is dull, heavy head- 
ache, sometimes with dizziness. Occasional periods of slight 
feverish excitement are noted in some cases ; the sleep is uneasy, 
disturbed, or heavy and unrefreshing. The skin becomes dry, 
wrinkled, and there may be eczema. 

When there is extensive atrophy of the gastric mucous mem- 
brane, the symptoms may be sufficiently severe to suggest 
cancer; if cirrhosis exists, it is probable that the tumor can be 
felt. 

Diagnosis. — Atonic dyspepsia at times bears a close resem- 
blance to chronic gastritis ; there is, however, much less sore- 
ness and tenderness in the epigastrium, no fever, the tongue is 
large and flabby, never of a character indicating inflammatory 
action, and there are generally manifestations of a neurotic 
condition. Cancer of the stomach is distinguished chiefly by 
the intensity of the pain experienced, which is also more con- 
tinuous, if not constant and circumscribed. The vomitus in 
cancer contains a free admixture of blood. The loss of flesh is 
noticeably rapid and the expressions of the cachexia are 
marked. The recognition of a tumor establishes the diagnosis. 
Aggravated cases of chronic gastritis may closely resemble 
cancer, especially cases where there is extensive atrophy of the 
gastric mucous membrane. 

Treatment. — The diet must be nourishing and easily digested. 
Special directions must be given to insure thorough mastica- 



CHRONIC GASTRIC CATARRH. 765 

tion and leisure in eating. Farinaceous substances and fats are 
to be largely eliminated, since they favor fermentative pro- 
cesses. Eggs, very lightly cooked ; tender, rare meat, espe- 
cially mutton and beef; oysters; rice and stale, white bread, 
usually agree. Cream and fresh butter may be used in modera- 
tion. A cup of hot meat-broth before a meal is grateful and 
acts as a gentle stimulant to the gastric mucous membrane. 
Tea and coffee must be used sparingly, if at all, and must be 
taken weak and without sweetening. 

The use of pepsin and other enzymes and digestants is not often 
of much benefit. Pepsin should not be prescribed in combination 
with bicarbonate of soda or other alkali ; a combination with 
dilute hydrochloric acid is preferable. Pancreatin may prove 
useful if, for some good reason, farinaceous substances cannot 
be wholly eliminated from the dietary. It is, however, safe to 
assert that the indicated remedy is far more capable of correct- 
ing the conditions for the control of which these enzymes are 
so constantly and freely exhibited. 

Lavage has been considered of the greatest value in all forms 
of gastritis, but especially in cases which are characterized by 
the presence in the stomach of large amounts of mucus. It 
thoroughly cleanses the stomach of the thick alkaline mucus 
which so strongly favors fermentation, and it stimulates 
glandular activity. Sterilized water, blood-warm, plain or 
medicated (sodium bicarbonate and chloride, a teaspoonful to 
the pint of -water ; antizymotics if fermentative processes are 
going on) should be used daily, preferably an hour before 
breakfast, the washing to be continued until the fluid returns 
clear and free from mucus and until the stomach has been 
entirely emptied. Ewald is very earnest in his praise of the 
results of this treatment, and is strongly indorsed by eminent 
clinicians. It is, however, a serious mistake to look upon it as 
universally indicated or useful. To many patients the treat- 
ment is exceedingly trying, and the results in general practice 
often fall short of accomplishing what there is claimed for it. 
"The apparatus that fulfills all the requirements for lavage 
consists of a fair-sized, well-fenestrated soft rubber-tube, either 
of black or red gum, and a hard-rubber funnel. This should be 
preferred to more complicated and expensive apparatus, or to 
hard-rubber stomach- tube used with the pump, the employ- 



766 DISEASES OF THE DIGESTIVE ORGANS. 

ment of which possesses no distinct advantage over siphonage 
with the soft tube, and even in the hands of the physician is 
not unattended with danger. The soft, red rubber-tube, the 
consistence of which is somewhat firmer than that of the pure 
(black) gum tube, is a trifle more convenient to introduce, as 
its ingestion can be accomplished without efforts at swallow- 
ing, and for that reason is preferable to the tube of pure gum. 
Either of these forms of tube may be employed. It must be of 
sufficient length for the intragastric extremity to reach the 
most dependent part of the stomach, and the external portion 
to extend several feet below the stomach level, to permit of 
ready siphonage. The wash- water should be introduced 
warm. The quantity used must be accurately noted, that all 
is withdrawn before removal of the tube. The water should 
be poured gently into the funnel. The latter must be held 
slightly above the head of the patient, who may be either 
seated or standing. After a pint, or more, of water has con- 
tinuously passed through the funnel and while the latter still 
contains sufficient to prevent the ingress of air with the fluid, 
the tube is tightly pinched between the fingers and the funnel is 
lowered to several feet below the stomach level, and the con- 
tents siphoned off b} r slightly inclining the former, so that an 
outflow will occur without a coincident entrance of air into the 
tube, which would check the action of the siphon. Water 
should then repeatedly be introduced and removed until it 
returns clear and free from susp'ended particles of mucus and 
food. If decided gastric catarrh exists, alkalies may be added 
to the wash-water. When fermentative processes are active, a 
pint or so of the last wash-water introduced should contain 
small quantities of a mild antiseptic, such as sodium borate, 
sulphite or salicjdate ; boric acid, the solubility of which is in- 
creased by sodium borate, may be used ; or, if preferred, naph- 
thaline, resorcin, benzoic acid, potassium permanganate, or 
any one of the many other antiseptic substances in common 
use, may be resorted to." (Hare.) 

The remedies to be consulted are those discussed under Acute 
Gastric Catarrh and Atonic Dyspepsia. 



NEUROSES OF THE STOMACH. 767 



NEUROSES OF THE STOMACH. 

Gastralgia, Gastrodynia, "Cramps at the Stomach," is an 
affection of the stomach chiefly characterized by severe pain at 
the epigastrium, often recurring in paroxysms ; it may be a 
local expression of general nervous irritability from weakness 
or a true neuralgia of the nerves of the stomach. 

./Etiology. — The chief causes of gastralgia are an inherited 
predisposition and conditions which develop a neuropathic 
tendency. Whatever exhausts the system increases this ten- 
dency. Hard work under unfavorable surroundings and with 
insufficient nourishment ; the long continued pressure of great 
responsibilities in persons of feeble strength or of a fretful dis- 
position, particularly when coupled with close confinement to 
counting-room or house ; the wear-and-tear of a life of contin- 
uous dissipation ; the excessive use of tobacco and alcohol ; the 
steady grind of the small worries of life, grief, jealousies and 
constant disappointments in trifling affairs quite as much as in 
matters of real moment, all these lower vitality, irritate an al- 
ready feeble nervous organization, and give rise, directly or in- 
directly, to this painful affection. Hence it is that the majority 
of sufferers from gastralgia are anaemic, irritable, anxious, 
fretful women, often the victims of uterine disease, chiefly at 
the menopause, perhaps brunettes oftener than blondes. How- 
ever, men are not exempt from the disease. Gastralgia is also 
seen as a feature of general neurasthenia and may be caused by 
chronic malarial poisoning. 

Symptoms. — The most important symptom is pain at the 
epigastrium, at times preceded by faintness and nausea, but 
often setting in without previous warning. The pain generally 
is severe, of a shooting, boring, burning, "cramp-like," charac- 
ter, pressive, often radiating into the chest and passing toward 
the back around the lower ribs. It may be almost unbearable, 
and is then accompanied with coldness of the extremities, pro- 
fuse cold sweat, irregular pulse, and a drawn, haggard, even 
hippocratic countenance. Light pressure usually aggravates, 
and deep pressure frequently relieves. The pain may be con- 
tinuous ; more often it is paroxysmal, with periods of rest be- 



768 DISEASES OF THE DIGESTIVE OBGANS. 

tween the spasms. Relief is sometimes, but not always, had 
from eating. The attacks may disappear suddenly or with 
copious eructations of gas, water and mucus, followed by a 
sense of relief, free voiding of pale limpid urine, and general re- 
laxation. 

Vomiting is observed in many cases, but is rarely persistent 
or severe. The appetite is usually good, save while the patient 
is suffering from an acute attack. Perversions of appetite are 
common, here as in other neurotic states, and in the pro- 
nounced hysterical cases there are found all the irrational de- 
sires for unwholesome substances, such as chalk, pencils, pow- 
dered brick, etc., which belong to hysteria. Bulimia is also 
noted in exceptional cases. 

The constitutional symptoms are those of a weakened, irri- 
tated, hysterical or neurotic state, including a tendency to 
neuralgia in various parts, unrefreshing sleep or sleeplessness, 
capricious disposition and general physical wretchedness. In 
other cases the patient enjoys fair health and may even have 
the appearance of one possessed of a vigorous, rugged consti- 
tution. 

Diagnosis. — The diagnosis depends largely upon the history 
of the case and the presence of neuralgia or other constitutional 
expressions of a neurosis. The exclusion of organic disease of 
the stomach (cancer, ulcer) is not always easy, for these are 
characterized by paroxj'sms of severe pain in the stomach 
closely resembling gastralgia, in the case of gastric ulcer in- 
cluding even periodicity of the paroxysms. In cardialgia there 
is relief from heavy pressure and often from eating ; in organic 
disease there is aggravation from deep pressure and from eat- 
ing. In the former, vomiting is rarely pronounced ; in the 
latter it is persistent and painful. In gastralgia, the par- 
oxysms having ceased, the patient usualh' can eat anything he 
likes ; in the organic diseases he must be constantly on his 
guard, for slight indiscretions may give rise to violent suffer- 
ing; furthermore, the tongue is red, when there is inflamma- 
tory action, and the course of the disease is progressively 
down-hill, tending toward a well-defined cachexia. Vomiting 
of blood is very unusual in gastralgia, but is common in gas- 
tric cancer or ulcer. 

Treatment. — The successful treatment of gastralgia involves 



NEUROSES OF THE STOMACH. 769 

strict attention to the general condition of the patient rather 
than to the local symptoms. Search for the primary cause 
usually opens the way to the intelligent treatment of the 
patient, which in many cases is psychical rather than physical 
or medicinal. The removal of all causes of irritation; the 
establishment of regular habits and the use of proper and sus- 
taining diet ; healthful and congenial employment ; life out-of- 
doors ; systematic exercise in the open air ; sometimes a change 
of residence — all these are of importance. 

To relieve the paroxysms of intense pain, copious draughts of 
hot water, hot fomentations over the epigastric region, some- 
times the application of mustard stirred in white-of-egg, are 
helpful. The use of anodynes, especially injections of morphine, 
is dangerous; Hoffman's Anodyne or small doses of chloro- 
form, from ten to twenty drops, is less liable to do harm and 
frequently comforts the patient. For therapeutic hints see the 
list of remedies at the end of this chapter. 

Nervous Dyspepsia. — A functional disorder of the stomach, 
characterized by gastric uneasiness and pain resembling that 
of acute gastric catarrh. It is accompanied with general nerv- 
ous depression and irritability, without real disturbance of the 
physiological process of digestion. 

The chief predisposing cause lies in a neurotic condition of the 
system, inherited or acquired. The exciting causes are condi- 
tions which in other cases might give rise to gastralgia or 
motor disturbances of the stomach. The influence of the mind 
upon physiological processes is more fully illustrated here than 
in almost any other abnormal state of the nervous system. 
While the patient nearly always complains of gastric uneasi- 
ness and even pain after eating, often with fulness and eructa- 
tions of gas, and at times really suffers severely, this is espe- 
cially marked when he anticipates harm from eating, either on 
general principles or because he fancies that the food of which 
he is expected to partake does not agree with him ; and he is 
rarely disappointed. On the other hand, if under the stimulus 
of some special excitement the stomach happens to be forgotten, 
the same person will eat a generous dinner and not suffer the 
slightest inconvenience. As Struempell remarks, sensitive per- 
sons are affected by the slightest psychical influences, and of 
all such, the most harmful is disquietude with regard to their 
49 



770 DISEASES OF THE DIGESTIVE ORGANS. 

own bodily condition. " The fear that a dish they have eaten 
may harm them, the constant dread that a serious disease of 
the stomach is in process of development, — such mental disquie- 
tude is it which is best calculated to maintain the unhealthy 
state and gradually to aggravate it. In this way a peculiar 
subjective hyperesthesia is developed which feels exquisite 
"pain" in the stomach when there is really nothing more than 
the ordinary normal sensation. And, in conclusion, there are 
developed in the same way certain half-unconscious, half-vol- 
untary movements which produce eructations, vomiting and 
the like. What we desire, therefore, to especially emphasize is 
our own conviction that in the large majority of cases of so- 
called nervous dyspepsia there is no functional derangement of 
the nerves of the stomach themselves, but a diseased "psycho- 
genous" excitation of the nerve centers, the consequences of 
which are expressed mainly in the domain of the digestive 
functions. Nervous dyspepsia is only a particular example of 
that great class of nervous diseases which owe their origin to 
hypochondriacal conditions of the mind, and which may occur 
in the most diverse organs of the body. This explains why the 
gastric symptoms are frequently attended by other nervous 
phenomena, among which may be mentioned symptoms of in- 
creased psychical irritability, headache, pressure in the head, 
vertigo and abnormal sensation in the extremities of cold or 
numbness." 

Practically, nervous dyspepsia is hypochondriasis of the 
stomach, and in spite of the inconvenience and unrest which it 
brings would not be of serious import were it not that the 
patient, concentrating his attention upon the stomach, lives in 
constant apprehension of coming evil, often fancying that some 
incurable disease has fastened itself upon him ; refusing to take 
proper nourishment, he slowly starves himself and thus con- 
tinuously increases that exhaustion of the nervous system 
which in reality is the primary cause of the whole trouble. 

The symptoms are those of indigestion, moderate and even 
trifling as to their intensity, but remarkable for their chronicity. 
There is rarely much pain, but a distressing sensation of fulness 
in the epigastric region is common, with eructations of gas, 
sometimes of mouthfuls of food, frequently sour and irritating. 
Flatulency in some cases is both gastric and intestinal, and 



NEUROSES OF THE STOMACH. 771 

causes inconvenience. Associated with it are palpitation of 
the heart, fitfulness of sleep, loss of appetite, headache, vertigo, 
general irritability, emaciation, constipation, and a more or 
less imposing array of nervous troubles, including coldness, 
numbness and prickling of the extremities, which usually throw 
the patient into a perfect agony of apprehension. 

Leube describes the folio-wing three forms: 1) Nervous dys- 
pepsia with normal secretion, gastric digestion taking place 
within its proper time-limit, but with discomfort and distress 
during the act of digestion, pressure, distension, eructations. 
2) A form in which there exists a reduction of the normal 
amount of acidity, the process of digestion here also being per- 
formed within the proper time limit. In addition to the gen- 
eral symptoms there are loss of appetite, sleeplessness and 
gastric distress, and when the stomach is empty there are un- 
easy local sensations, general feeling of malaise, headache and 
dizziness. 3) A form in which there is hyperacidity of the gas- 
tric juices, the percentage of acid being sometimes doubled. 
Digestion in these cases is liable to be retarded, especially of 
farinaceous foods, and burning eructations and vomiting, with 
considerable distress, are among its most prominent symp- 
toms. This condition at times occurs in paroxysms, usually at 
long intervals, and is described by Rossbach under the term 
"gastroxynsis." It is rare, and "when seen occurs usually as a 
symptom of profound neurasthenia or with locomotor ataxia. 

Treatment. — The treatment of nervous dyspepsia must be 
largely aimed at the constitutional state back of it. The Weir- 
Mitchell method is said to be, and should be, very helpful in 
such cases. If there is hyperacidity, a farinaceous diet must be 
prohibited, and meat, raw or rare, substituted. Excessive flat- 
ulency invariably indicates restriction in starchy, fat and sweet 
foods; when associated with a tendency to constipation, it not 
infrequently finds relief by copious flooding of the colon just 
before retiring. 

Of course, the management of a patient's diet in such cases 
tries the skill of any physician, and it is sometimes practi- 
cally impossible to change the notions of the patient as to 
what he should, or should not, eat, and to enforce obedience. 
This class of people usually read everything within reach con- 
cerning foods and insist upon making of themselves labora- 



772 DISEASES OF THE DIGESTIVE ORGANS. 

tories for the benefit of the manufacturers of special food-prep- 
arations. It is well to humor the patient so far as is consistent 
with his interests, and by an abundance of exercise in the open 
air, baths, occasional change of faces and scenery, by providing 
wholesome amusement and employment, to build up his gen- 
eral health and to draw his attention from his stomach, im- 
pressing him with the probability of eventual recovery by over- 
coming the constitutional tendency at the bottom of all his 
troubles. 

Nervous vomiting occurs chiefly in hysterical women, espe- 
cially in brunettes. No lesion of the stomach can here be dis- 
covered ; it is therefore assumed that the vomiting is due to 
nervous influences exerted upon the centres presiding over the 
act of vomiting. The distinguishing feature of the act itself lies 
in absence of preliminary nausea and of retching ; neither do the 
muscles of the abdomen and chest appear to participate, for 
the act itself resembles large eructations rather than vomiting. 
The vomiting in the majority of instances occurs after eating, 
but not necessarily so ; it may come on at any time in par- 
oxysms and at irregular intervals. In some aggravated cases 
paroxysms of gastralgia have been observed, with much pros- 
tration and general upsetting of the nervous S} r stem. How- 
ever, in the large number of instances the general health re- 
mains good. Struempell includes under this head the vomiting 
after every meal from which school children of both sexes occa- 
sionally suffer. 

The similarity of the paroxysms described as "periodical 
vomiting with paroxysms of gastralgia" to the gastric crises 
of tabes dorsalis is recognized by writers and clinicians. 

Treatment consists chiefly of the persevering employment of 
the same agencies, principally of a moral character, which are 
so important in all neuroses. The improvement in the general 
health and the modification and amelioration of the neurotic 
condition per se is the first thing to be attained, and whatever 
brings about the latter must of necessity exert a favorable 
effect upon the former. Sponging and bathing in cool water 
has a desirable tonic effect ; it is especially useful in the case of 
children of a nervous, irritable disposition who suffer from this 
cause. 

Peristaltic unrest is a term used to describe an irritable con- 



NEUROSES OF THE STOMACH. 773 

dition of the motor nerves of the stomach or of the correspond- 
ing nerve centers. This condition was carefully studied by 
Kuessmaul. It occurs in connection with neurasthenia, and 
consists of an increased peristalsis of the stomach, in some 
cases also involving the intestines, with distinctly audible 
gurgling sounds, heard at some distance, in the stomach and 
bowels, and borborygmi. Exceptionally this peristaltic action 
has been reversed and ' 'colored enemata and even scybala have 
been discharged from the mouth." 

Other forms of gastric neuroses have been described, but are 
of slight, if any, interest to the general practitioner. Of these 
the most important is rumination of food, in which the food is 
regurgitated and chewed like a cud. It is sometimes hereditary, 
and is seen in hysterics, epileptics and idiots. It has no no- 
ticeable effect upon the health. 

Treatment of the Neuroses. — Electricity, it is claimed by 
electro-therapeutists, has been employed with satisfactory re- 
sults. Thus, in the treatment of gastralgia, Rockwell places 
much confidence in the use of the faradic current of high tension 
in cases where from pressure over the seat of pain relief is 
afforded; galvanism, when pressure increases the pain. "In 
using the galvanic current I prefer electrodes of plastic sculp- 
tor's clay, placing the anode over the seat of pain. In this 
way currents of 20 to 25 milliamperes are readily borne." 
In atony of the stomach the same authority places electricity 
in the front rank of our therapeutic resources, recommending a 
faradic current of rapid interruption and high tension, used 
generally and locally. The electrodes chosen should be large 
and the pole over the region of the stomach should be kept in 
constant motion to avoid painful muscular contractions. In 
spasm of the stomach the faradic current should be used, a 
"large electrode being applied a little to the left of the spinous 
processes and at a level with the cardiac end of the stomach. 
The other electrode, by preference the cathode, is applied suc- 
cessively with constant movement over the entire surface of 
the gastric region." 

Therapeutics. — In Gastralgia the following are especially 
useful: Phosphorus, Plumbum, Belladonna, Nux vomica, 
Argentum nitricum, Stannum, Ignatia, Bryonia, Ferrum, 
Bismuth, Arsenic, China, Dioscorea, Pulsatilla, Petro- 
leum. 



774 DISEASES OF THE DIGESTIVE ORGANS. 

Consult also : Asa fcetida, Calcarea, Carbo yegetabilis, 
Chelidonium, Chamomilla, Colocynthis, Gelsemium, Lep- 

TANDRA, LYCOPODIUM, IRIS, LOBELIA, ^EsCULUS, SlLlCA. 

In Nervous Dyspepsia : Nux vomica, Ignatia, Phosphorus, 
Calcarea, Bryonia, Carbo vegetabilis, Hydrastis, Arsenic, 
Argentum nitricum, China, Pulsatilla, Anacardium, Asa 
fcetida, attrum, berberis, blsmuth, ipecacuanha, iris, kali 
carbonicum, Lachesis, Leptandra, Lycopodium, Mercury, 
nux moschata, sepia. 

Consult also : Arnica, ^Esculus, Alumina, Cina, Magnesia 
muriatica, Agaricus, Antimonium crudum, Dioscorea, and the 

MINERAL ACIDS. 

In Nervous Vomiting: Ignatia, Nux vom., Pulsatilla, 
China, Asa fcetida, Ipecacuanha, Lachesis, Lycopodium, 

Nux MOSCHATA. 

In the motor neuroses : Nux vom., Strychnia, Ignatia, Asa 
fcetida, Phosphorus, Gelsemium, Plumbum, Lycopodium. 

Anacardium. Excessive weakness and irritability of the nerv- 
ous system from long-continued and excessive mental effort. 
Wants to eat at all times, because of faintness and goneness, 
but finds no relief from it. Twitching of muscles. Melancholia 
and hypochondriasis, with weakness of memory. Digging, 
throbbing headache, better from eating, worse from thinking. 
Paralytic weakness in the legs, especially in the knees, so he is 
scarcely able to walk. Eczema, with excessive itching and 
burning. — Argentum nitricum. Gnawing, ulcerative, sore 
pain, with sensitiveness to slight pressure, confined to a small 
spot between the xyphoid cartilage and the umbilicus, radiat- 
ing to the back, shoulders, hypochondria. Great flatulency; 
the stomach seems ready to burst ; copious, violent eructa- 
tions, accomplished only after persistent effort. Nausea, with 
palpitation. Severe pain at the epigastrium, as from a stone 
in the stomach, with painful, ineffectual attempts to eructate. 
The pain increases and decreases gradually ; when at its height, 
relief from making violent pressure with the clenched fist in the 
pit of the stomach. Great mental depression, anxiety, worry. 
Tremulous weakness of the whole body. Nervous affections 
resulting from alcoholic or sexual excesses. — Arsenicum. Of 
particular value if the history of the case is one of previously 
existing gastric catarrh, especially from the unwise use of ice- 



NEUROSES OP THE STOMACH. 775 

cold drinks or tobacco. General exhaustion of the nervous 
system. Great irritability of the stomach ; it refuses food and 
drink. Heartburn. Gulping-up of acrid fluid, excoriating the 
throat; fulness and tenderness to pressure in the epigastric 
region. Constrictive pain in the stomach when empty. Nausea 
and vomiting, better from taking hot drinks, especially milk. 
Violent burning pain in the stomach. Attacks of sudden weak- 
ness. Characteristic thirst, restlessness, anxiety. Coldness of 
the skin. Anaemia. Rapid exhaustion. Although of particular 
value in acute catarrh of the stomach, it is very useful in gas- 
tralgia when the patient becomes exhausted rapidly and the 
general characteristics of the remedy are present. — Asafostida. 
Excessive gastric and intestinal flatulency, with distension, in 
nervous, hysterical women. She cannot relieve herself of the 
flatulency ; it refuses to pass downward, and must be brought 
up from the stomach. Physical and mental hypersensitiveness. 
Craving for wine. Globus hystericus. Regurgitation of food. 
"It seems as if the peristaltic action of the bowels were re- 
versed." (T. F. Allen.) — Aurum. Flatulency with pain at the 
heart and palpitation. Burning and pressure in the stomach, 
with hot rising. Relief of gastric pain and palpitation by 
eructations of gas. Profound melancholy with weeping and 
crying. — Belladonna. Gastralgia. Gnawing, pressing pain, 
or wrenching pain extending to the spine, or spasmodic tension 
which makes the patient bend backward or stop breathing, 
which seems to afford some relief. Tired feeling in the spine ; 
attempts to rest the spine by bending backward ; pain exces- 
sive, hardly endurable. Acuteness of all the senses. Impa- 
tient, demonstrative, and intolerant of pain. Extreme tender- 
ness in the epigastrium. He cannot bear the slightest touch, 
pressure or jar. — Berberis. Nervous dyspepsia. The patient 
is melancholic, listless, depressed. Prostration so great that 
he sweats freely from the slightest motion. Bilious tendency. 
Offensive, metallic odor from the mouth, which is dry and 
sticky. Eructations, heartburn, vomiting of food after eating. 
— Bismuth. Gastralgia. Burning and pressure in the stomach 
after eating. Pain confined to one small spot, with sense of 
heaviness as from a load, forcing him to bend backward. 
Sweet, metallic taste in the mouth; thirst for cold drinks, 
which are promptly rejected. Intense malaise, with burning 



776 . DISEASES OF THE DIGESTIVE ORGANS. 

pain in the spine, forcing him to bend backward. Waterbrash ; 
flatulence; prostration. "While taking cold drinks, there is 
relief; yet, when the stomach becomes full, there is vomiting of 
enormous quantities." — Bryonia. Pressure in the stomach 
from indiscretions in diet; it comes on when the stomach is 
empty or full ; pressure as of a heavy stone, continuing for sev- 
eral hours and passing off with copious eructations. Sour ris- 
ings, heartburn, vomiting of sour, acrid mucus. Sensitiveness 
of the stomach to external pressure ; craving for coffee, wine, 
acids. Yellow coating of the tongue. Bitter taste in the 
mouth. Stitches in the stomach. Contractive, pinching pain 
in the stomach, relieved by eructations. All the symptoms are 
worse from motion. Tongue coated heavy, white. Great sen- 
sitiveness in the epigastrium to touch. Vomiting of food. — 
Calcarea carbonica. Of use chiefly in chronic cases of nerv- 
ous dyspepsia in fagged-out house- wives of characteristic tem- 
perament and with the constitutional indications of the remedy. 
Tongue coated thick, whitish-yellow. Loss of appetite. Posi- 
tive disgust for meat and warm food; prefers all food cold. 
Bitter, putrid, sour taste. Bloating and fulness after eating. 
Sensitiveness at the pit of the stomach. Palpitation of the 
heart from weakness. Profuse accumulation of saliva in the 
mouth, appearing to relieve the stomach symptoms for a time. 
Malnutrition with sluggishness, profuse sweating, coldness of 
the extremities, inability to bear an exertion. Sometimes raven- 
ous hunger and thirst, with longing for eggs and indigestible 
substances. Acidity of the stomach ; everything he eats turns 
sour; sour risings; heartburn; sleeplessness. — Carbo vegeta- 
bilis. Useful in cases of nervous dyspepsia of persons who 
have been high livers. Flatulency; sour, rancid eructations, 
with much soreness in the epigastrium. Aversion to food, with 
occasional violent spasmodic contractions in the epigastrium, 
worse at night, better from eructations. Nausea, not often 
vomiting, relieved temporarily by taking an alcoholic stimu- 
lant or strong coffee. Sense of trembling and of heavy weight 
in the stomach. Cannot bear milk, meat or fats of any kind. 
Stomach swollen like a drum. Inertia of the stomach ; cannot 
digest anything, no matter how simple. Coldness of the sur- 
face of the body, with feeble pulse. Often very useful in the 
gastralgia of nursing women, with excessive flatulence, sour 



NEUROSES OF THE STOMACH. 777 

and rancid belching, vomiting of food. Resembles Bismuth in 
that the epigastric pain and burning often extends into the 
spine. — China. In anaemic and malarial conditions. Acidity ; 
"goneness" and faintness at the stomach, better from eating, 
but only for a short time. Coldness in the stomach. Craving 
for stimulants and pungent, refreshing things; cannot eat 
farinaceous food; slowness of digestion, with cramps and 
pressure after eating ; vomiting of ingesta ; ill humor ; indispo- 
sition to make an exertion. After eating he is obliged to lie 
down and rest; cannot work. — Dioscorea. Acts powerfully 
upon the coeliac and umbilical plexus ; useful in persons with 
weak digestion and tendency to colic. Burning at the stomach, 
with sharp pricking pain and faintness. Belching of large 
quantities of gas. Pains radiate in all directions and appear 
constantly in the head and feet. Said to be very helpful to per- 
sons suffering from the excessive use of tea. " Neuralgia of the 
stomach, most severe pain even along the sternum and extend- 
ing into both arms, with cold, clammy sweat, etc." — Ferrum. 
In anaemic persons, subject to neuralgia and disturbance at the 
heart. Nervous dyspepsia. Heavy pressure at the pit of the 
stomach. Vomiting immediately after eating, without nausea ; 
brought on by moderate exertion. Intolerance of milk. Pain 
better from vomiting. Weak and restless; must keep on the 
move, yet is greatly exhausted by it. Intolerance of pain. 
Though anaemic, the face flushes scarlet from slight emotion 
or without cause. Extremities cold. Ravenous hunger or dis- 
gust of food. Diarrhoea after eating. — Hydrastis. Weak diges- 
tion, with heavy, hard, thumping pain ; fulness of the chest ; 
dyspnoea; empty, gone, faint feeling at the stomach; pulsa- 
tions at the pit of the stomach ; palpitation at the heart ; sour 
and bitter eructations; pyrosis; aggravations from eating; 
large, flabby tongue, looking as though covered with slime. 
Tendency to catarrh and ulceration of the mucous membrane, 
debility and constipation. Nervous dyspepsia of old people. — 
Ignatia. Great nervous prostration and irritability. Loss of 
appetite; musty eructations; bloating after meals, with hic- 
cough from eating or drinking. Fair appetite, but a fewmouth- 
fuls of food satisfy him ; he cannot eat a full meal. Faintness, 
emptiness, goneness at the stomach. Flatulency and colic, 
especially at night. Oppressed, sighing breathing, with palpi- 



778 DISEASES OF THE DIGESTIVE ORGANS. 

tation of the heart. Periodical cramps at the stomach, occa- 
sionally with canine hunger and qualmishness. Absolute ano- 
rexia, with aggravation of constitutional weakness from the 
lack of proper food. Sense of pressure, as from a stone, in the 
pyloric region. Gnawing, cutting pain; sensitiveness in the 
pit of the stomach. Of great value in stomach troubles of 
habitual smokers. Characteristic despondency and hysterical 
excitement. — Ipecacuanha. Useful when there is constant 
nausea with tendency to vomit and aversion to all food, due 
to nervous influence rather than gastric irritation. — Iris versi- 
color. Although more directly indicated in gastric catarrh 
than in the neuroses, it yet holds an important part in the 
treatment of the latter when the symptoms are of unusual 
violence and border upon the inflammatory. There is great 
burning distress in the stomach; vomiting of sour food and 
acrid, watery substances ; belching of gas and great heartburn. 
Bilious s\ r mptoms ; bilious vomiting ; bilious diarrhoea ; acrid- 
ity of all discharges and burning, smarting in the parts over 
which they pass. — Kali carbonicum. In old people "who are 
constantly chilly, never perspire, have pallor of the face, oedema 
of the upper eye-lids, great desire for sweet things, bloatedness 
of the abdomen, dryness of the mucous surfaces, dry hard 
stool, turbid urine." Bloating; sour eructations; heartburn; 
feeling of weakness or of a lump in the pit of the stomach. 
Attacks of gastralgia, with sharp cutting, stitching pain, from 
drinking ice-water. — Lachesis. Indicated by excessive sore- 
ness at the stomach to touch, with intolerance to slightest 
touch or pressure, even from the bed-clothing. Perceptible 
trembling in the epigastric region ; foul cadaverous taste. — 
Leptandra. Useful in exceptional cases when a bilious state 
prevails, characterized by flat, pappy taste and black, fetid, 
tar-like copious stools. Nausea, with death-like faintness upon 
rising. Great gastric and hepatic distress, worse from drink- 
ing water. — Lycopodium. In chronic cases of nervous dyspepsia 
and gastralgia, with immense distension of stomach and in- 
testines from gas. Ravenous hunger, but he bloats at once 
and cannot eat on account of it ; or sense of extreme fulness 
even before eating, so he cannot take food. Acid dyspepsia. 
Eating solid food increases all the symptoms. Extreme flatu- 
lence in chronic cases is the most characteristic indication. 



NEUROSES OF THE STOMACH. 779 

Great exhaustion; brick-dust sediment in the urine. — Mer- 
curius. In chronic cases of moderate severity and with liver 
complications. Foul, sweet, brassy, saltish, bitter taste in the 
mouth, especially in the morning. Wants spices, highly sea- 
soned foods, cold drinks, alcoholic stimulants. Slimy mouth. 
Suspicious, vehement disposition. — Nux moschata. In hys- 
terical women. Great flatulency, brought on by any excite- 
ment as quickly as by eating. Natural appetite, but satisfied 
by a few mouthfuls of food. Faintness ; enormous bloating at 
the stomach. Mental efforts aggravate all the symptoms. — 
Nux vomica. Most useful in cases of nervous irritability and 
exhaustion from overwork, especially of a sedentary character, 
the immediate attack often provoked by imprudence at the 
table. Cross ; easily irritated ; gets angry at trifles and tol- 
erates no interference or contradiction. Sallow complexion. 
Dull, frontal headache, especially in the morning ; inability to 
make a prolonged mental effort ; constipation. Fulness and 
distension after a meal; sensitiveness to pressure; tightness 
about the waist; lassitude, nausea, vomiting of bile and food. 
Bitter, sour, insipid taste. Cannot eat bread, milk or acids. 
Usually aggravations from eating. Heartburn. Desire for 
stimulants. Pain in the stomach as though it were knotted up. 
Persistent efforts to vomit food. In gastralgia ; the stomach 
makes spasmodic contractions upon the food ; light pressure 
affords relief. In case of habitual users of alcoholic stimulants 
and strong drugs. — Petroleum. Emptiness and weakness at 
the stomach. Water-brash. Drawing, pressing pain at the 
stomach. Constant nausea. Nausea with accumulation of 
water in the mouth. The persistency of the nausea and the 
temporary relief which is regularly experienced from eating are 
the symptoms most characteristic of this remedy. — Phos- 
phorus. The gastric trouble is the result of general exhaus- 
tion of the nervous system from fast living, especially sexual 
excesses. Alike useful in nervous dyspepsia and gastralgia. 
Great prostration ; dryness of the throat and of the tongue ; 
sour taste. Regurgitation of food ; burning pain in the stom- 
ach, with thirst for cold drinks, which are ejected as soon as 
they become warm in the stomach. Constant loud rumbling 
of gas in the stomach, with eructations of gas, which afford 
only slight relief and do not appear to lessen the flatulency. 



780 DISEASES OF THE DIGESTIVE ORGANS. 

Oppression of the chest, proceeding from the stomach and worse 
after eating. Burning, gnawing pain in a circumscribed spot 
in the stomach, which is very sensitive to the slightest pressure. 
This pain extends directly backward to the spine, is made worse 
from motion and eating, better from rest and, for a short time, 
by cold drink. Faintness, emptiness, gnawing at the stomach, 
relieved temporarily by eating. Vomiting of the entire contents 
of the stomach, sometimes with an admixture of blood. — 
Plumbum. Gastralgia ; the paroxysms are violent in charac- 
ter and come on very suddenly. The pain compels the patient 
to bend backward ; it is relieved by deep, hard pressure and by 
eructations. The entire abdomen draws in and feels hard and 
tense like a board. Sensation as if the abdominal walls were 
drawn far in and were touching the spine. Periodic vomiting 
of food, or of brown, dark liquid, accompanied with severe 
cramps. — Pulsatilla. Nervous dyspepsia; tongue coated 
thick, with whitish, rough fur; taste sticky, pasty, as from 
spoiled milk ; repugnance to warm dishes ; absense of thirst. 
Digestion exceedingly slow ; he continues to taste the food long 
after it has been swallowed ; regurgitation of food for a long 
time after eating ; pain in the stomach beginning an hour, or 
more, after eating. Hiccough ; rumbling in the bowels. Feel- 
ing as if a lump had lodged in the gullet. Gnawing sensation 
in the stomach when empty. Sour and bitter eructations and 
vomiting. Indigestion easily brought on by eating rich pastry, 
fats, buckwheat cakes, or drinking ice-water. Gastralgia, with 
similar symptoms and profuse sweating of the face. — Sepia. ■ In 
women who suffer from menstrual or uterine difficulties. Sour, 
putrid taste; aversion to meat; desire for sour things; empti- 
ness in the stomach, with anguish ; palpitation ; weakness and 
weariness of the legs; sour and putrid eructations. Hypo- 
chondria, especially at the climacteric. Amenorrhcea. Aggra- 
vation of nausea and vomiting from eating and lying down. 
Longing for acids. Feeling of something twisting about in the 
stomach and rising into the throat. The pain comes on grad- 
ually, steadily grows worse, then as gradually disappears to 
return in the same manner. It is very obstinate ; relieved by 
pressure. Sinking, gone feeling at the pit of the stomach; 
canine hunger ; great uneasiness, compelling him to walk about ; 
he soon tires and sits down, but again walks about, impelled 



DILATATION OF THE STOMACH. 781 

by a feeling of restlessness, with temporary relief from the ex- 
ercise. — Stannum. The pain is obstinate; it gradually in- 
creases and as gradually decreases, getting better and worse 
gradually. It extends to the navel and is relieved by hard, 
steady pressure. Sinking, gone feeling at the pit of the stom- 
ach; canine hunger; relief from walking, but he is so weak 
that he is forced to desist soon. 

DILATATION OF THE STOMACH. 

Dilatation of the stomach, also called gastrectasis or gastrec- 
tasia, must be distinguished from magastria, a more than 
usually large stomach which performs all its functions in a 
normal manner. 

Etiology. — Acute dilatation of the stomach is exceedingly 
rare, and is the result of the introduction into the stomach, 
within a short time, of an inordinately large amount of food or 
drink. Chronic dilatation is not infrequent, and is due to me- 
chanical obstruction of the pylorus or to atony of the muscu- 
lar wall of the stomach. Obstruction or narrowing at the 
pylorus or duodenum in the great majority of cases arises from 
cicatrization of cancerous ulceration or, less often, simple gas- 
tric ulcer ; very exceptionally the stricture may be congenital. 
Violent inflammation of the stomach, involving the deeper 
structures (phlegmonous or toxic gastritis) may also result in 
pyloric obstruction from cicatrization. Other causes are: 
pressure of tumors from within (polypi) or from without 
(tumors of the pancreas, liver, omentum, floating kidney?), 
cicatricial bands from an old peritonitis, or a large scrotal 
hernia, dragging down the transverse colon or the omentum. 

Atony of the musular walls may be so great that the expul- 
sive power of the stomach is wholly inadequate to the task 
imposed by the digestion of an average meal (absolute atony), 
or it may prove inefficient only when there is made upon it an 
unusual demand (relative atony). It may also result from local 
causes, as a gastritis, or from impaired nutrition of the organ, 
as an incidental factor in the course of neurasthenia, anasmia, 
cancer, tuberculosis, or some other grave constitutional dis- 
ease. Again, the fermentative changes going on in a tedious 
case of chronic gastritis are in themselves capable of so stretch- 



782 DISEASES OF THE DIGESTIVE ORGANS. 

ing the walls of the stomach as to become important factors 
in producing dilatation. The same, within certain limitations, 
applies to the persistently large quantities of food and drink 
consumed by diabetics, excessive beer-drinkers, and the insane. 

The greater number of cases are seen in the middle-aged ; oc- 
casionally instances of dilatation are found in rickety children. 

Hypertrophy about the pylorus usually precedes dilatation. 
This is due to the endeavor on part of the muscular tissues to 
overcome the difficult propulsion of food out of the stomach. 

Symptoms.— The symptoms are those of indigestion, modi- 
fied by the symptoms of any disease of which the dilatation is 
an incident. There is disturbed and capricious appetite, gas- 
tric uneasiness and discomfort, flatulency and vomiting. The 
latter is almost characteristic, taking place at irregular inter- 
vals which increase as the dilated stomach becomes capable of 
holding increasing amounts of food and drink. In a well-de- 
veloped case vomiting may take place only every few days, 
the quantity then ejected being large, amounting even to sev- 
eral quarts. There sometimes is some retching, but usually the 
act is accomplished without effort or pain. The vomitus is of 
dark-grayish appearance, of distinctly sour odor, due to the 
acids present, and often contains particles of food which were 
eaten days before. If allowed to stand, three separate layers 
may be seen. A frothy, brownish layer on top ; below this, a 
muddy, dark-gra3 r ish fluid ; at the bottom a layer of food. 
Microscopic examination shows many bacteria and moulds, 
with yeast fungi and sarcina ventriculi ; also crystals of fatty 
acids. 

Hydrochloric acid is present in varying amounts ; it may be 
diminished, increased, or wholly absent. 

In the progress of the disease very little fluid can escape from 
the stomach ; this accounts for the scantiness of urine, consti- 
pation, and great dryness of the skin. The urine is diminished 
in acidity and often is persistently alkaline. Constipation is 
present in the great majority of cases, but sometimes there is 
diarrhoea. Nutrition necessarily becomes bad, and the patient 
progressively loses strength and at last suffers from extreme 
emaciation. Depression of spirits, eructation of foul gas from 
the stomach, headache, dizziness, sleeplessness, with palpita- 
tion of the heart and difficult, oppressed breathing, are noted 
as the case advances. 



DILATATION OF THE STOMACH. 783 

Kuessmaul has described a form of tetany which is seen in 
some advanced cases of dilatation, after profuse vomiting or 
lavage. The spasms are tonic, involve the flexors of the foot, 
arm, hand, calf, and abdominal muscles ; sometimes they are 
general and continue for a few minutes to a few days. 

The most positive symptoms, however, are elicited by various 
methods of physical examination. By Inspection, the patient 
standing, it is usually possible to determine the outlines of the 
dilated stomach. There is great enlargement of the abdomen, 
most conspicuous below the umbilicus. The lesser curvature, 
which is not so often clearly visible, is distinguished a little 
below the ensiform cartilage, while the greater curvature can 
be folio wed on the left from the tenth rib toward the pubes, 
then sweeping upward on the right to the costal margin. The 
peristaltic movements may also be seen, proceeding from left to 
right, sometimes the reverse. In some cases the stricture itself 
may be detected, the hypertrophied mass, tumor-like, showing 
through the thinned abdominal wall. Frerichs advises the ad- 
ministration of a half-drachm each of the bicarbonate of soda 
and of tartaric acid, one after the other, for the purpose of 
artificially distending the stomach when making inspection. 
Palpation verifies the peristaltic movements and conveys to 
the hand a sensation of elastic resistance of the stomach, as 
from an air-cushion. By striking quick, sharp blows with 
either hand alternately upon the walls of the stomach, a 
splashing sound (clapotage) is produced. Percussion is 
comparatively difficult and unsatisfactory, but it is an 
aid in doubtful cases. It must be practised with the pa- 
tient in both the erect and recumbent position and when the 
stomach is full and empty. If the patient is directed to drink 
about a quart of water when the stomach is empty, and then 
is made to assume the standing posture, percussion will define 
the lower boundary of the stomach by establishing a well- 
defined line of dulness. If this line is below the umbilicus, there 
is reason to believe that dilatation exists, although we must 
bear in mind the possibility of dealing with a displacement, 
downward, of the stomach. 

Auscultation yields splashing sounds if a series of sudden, 
forcible impulses with the hand are given. To render this 
otherwise unreliable sign of positive value, auscultation should 



784 DISEASES OF THE DIGESTIVE ORGANS. 

be practised about two, or more, hours after drinking freely, • 
then removing the water from the stomach by means of a 
siphon. If, after emptying the stomach, the same splashing 
sounds are not reproduced, it is safe to consider them of diag- 
nostic value. The heart-sounds, with a dilated stomach, are 
transmitted with great distinctness and with a metallic 
quality. Mensuration by means of a hard sound introduced 
into the stomach is of slight practical value. 

The diagnosis depends upon clearly establishing the greater 
curvature of the stomach below the umbilicus, upon the char- 
acter of the vomitus, and upon such knowledge as can be ob- 
tained by means of the stomach pump, showing for how long 
a time food has been retained in the stomach. The diagnosis 
is especially difficult in the early stage, when it may be im- 
possible to differentiate between dilatation and a normal, but 
large, stomach, with a low form of gatritis or atony of the 
muscular wall. 

The prognosis is rather favorable if the affection is detected 
before dilatation has become large and habitual. Indefinite 
prolongation of life and great general improvement may be 
hoped for in the absence of malignant disease or extreme ex- 
haustion. When the local affection is the result of a grave con- 
stitutional disease, as tuberculosis, the prognosis cannot be 
encouraging ; when associated with, or dependent upon, ma- 
lignant processes, it must necessarily be hopeless. 

Treatment — Since Kuessmaul first employed lavage, it has 
become the means of affording great relief to otherwise incur- 
able cases by removing from the stomach contents undergoing 
fermentation, cleansing the organ, and by encouraging it to 
contract. The operation has been described (see chapter on 
Chronic Gastric Catarrh). Pure water may be used, or, if fer- 
mentative processes are active, a one per cent, solution of sali- 
cylic acid, or sodium borate, resorcine, potassium permangan- 
ate, or some other antiseptic substance. 

Electricity. — Einhorn, Rockwell and others highly recom- 
mend electricity. Rockwell cites a case in which remarkable 
and permanent improvement resulted from the direct applica- 
tion to the stomach of a faradic current of slight tension, ap- 
plied by means of a bipolar electrode, combined with general 
faradization. H. G. Piffard places an ordinary faradic appa- 



SIMPLE ULCER OF THE STOMACH. 785 

ratus in shunt with the current. Each time the circuit is closed 
by the rheotome the current will be increased, and diminished 
each time the circuit is opened. The effect of this rapid fluctua- 
tion in the current is to produce muscular contraction resemb- 
ling that caused by a strong faradic current. This current, 
internally applied through a stomach electrode, has proved 
very useful in dilatation of the stomach. 

Diet must be carefully regulated, so as to represent a large 
amount of nourishment in the smallest possible bulk ; neither 
should the food selected ferment readily. To increase the mus- 
cular energy of the stomach, massage may prove helpful; it 
also aids in forcing the passage of food from the stomach into 
the intestine. Hypodermic injections of strychnia are recom- 
mended for their tonic effect upon the muscular fibre. Hydro- 
chloric acid, carbolic acid, kreosote, salicylic acid, and others 
of this class are used to control the fermentative processes. 

Surgical measures for the forcible dilatation of pyloric strict- 
ure or for the removal of the cicatricial mass have been em- 
ployed. Occasional brilliant results have been announced, but 
in the main the mortality has been high. 

The nature of this affection is such that internal medication 
cannot be expected to do more than relieve such special symp- 
toms as may arise from time to time and possibly strengthen 
the muscular tissues of the stomach. Seutin (Journ. Beige 
d'Homeopathie) claims to have used the following -with good 
results: Arnica, Antimonium crudum, Arsenicum, Bryonia, 
Chamomilla, Cocculus, Cuprum, Colocynthis, Graphites, 

Nux VOMICA. 

Nux vomica and Strychnia are undoubtedly the most prom- 
ising remedies to give tone to the exhausted muscular fibre of 
the stomach. E. M. Hale says : "I have found the alternation 
of hydrastis, hydrastine or muriate of hydrastine with nux 
vomica or strychnine to give better results than any other 
medicinal treatment." 



SIMPEE ULCER OF THE STOMACH. 

Simple (peptic, round, rodent, penetrating) ulcer of the stom- 
ach occurs in both sexes, nearly twice as often in women as in 
men. In the former, it is commonest during the third, in men 
50 



786 DISEASES OF THE DIGESTIVE ORGANS. 

during the fourth, decade of life. Very young children and peo- 
ple of advanced years are almost exempt. Occupation may 
have a bearing when it involves possible injury to the stomach, 
as from long-continued pressure upon it ; it is thus that the 
comparative frequenc3 r of the affection among weavers, tailors 
and shoe-makers is explained. It is oftener seen in anaemic, 
weak, chlorotic persons than in those of rugged health. 

The specific cause of the ulcer has not yet been positively 
determined. It is, however, generally assumed that it is a case 
of self-digestion of the stomach (hence, peptic ulcer), involving 
a limited area whose nutrition has previously been interfered 
with. Virchow suggests that thrombosis or embolism of a 
minute blood-vessel thus constitutes the first cause of the ulcer. 
It has been demonstrated that alkalinhVy of the blood or hyper- 
acidity of the gastric juice are frequently occurring features of 
the disease. 

Simple ulcers are known to follow mechanical injuries, burns 
or a blow upon the stomach; they are also found in connection 
with heart-disease, circumscribed stasis in the circulation of the 
stomach, etc. The affection is not always recognized during 
life ; examinations after death constantly reveal the presence of 
ulcers in the stomach, usually cicatrized, the existence of which 
had not been suspected v 

Simple ulcers may occur in the duodenum, preferably near the 
pylorus, and are more frequent in men than in women. 

Morbid Anatomy. — Peptic ulcer is usualfy single, but may be 
multiple, not often more than three or four in number. Not- 
able exceptions have occurred. Berthold records a case in 
which thirty-four ulcers were counted, and one of Fagge's cases 
after death showed "that almost the whole of the mucous 
membrane of the stomach was diseased. There were numerous 
recent ulcers with raised, irregular edges, and there were also 
many thickened, puckered cicatrices." 

In shape the ulcer is round or oval, sometimes irregular. Its 
borders are sharply cut, giving it a " punched-out " appear- 
ance ; the walls slope inward, rendering it funnel-shaped ; grow- 
ing older, the walls become indurated and thickened, and thus 
lose the sharpness of their outline. The base is usually clean, 
differing in appearance with the depth of the ulcer. Its size 
varies greatly. It may not be larger than a small pea, but 



SIMPLE ULCER OF THE STOMACH. 787 

more often attains a diameter of one-half to two inches. Pea- 
body reports a case in which the nicer involved all the lesser 
curvature and a large portion of the anterior and posterior 
wall. The favorite position is at the lesser curvature, near the 
pylorus, on the posterior wall of the stomach ; but the anterior 
wall and the greater curvature may be involved. 

The healing of a single ulcer of moderate size and of a super- 
ficial character takes place from the edges and floor, the tissues 
gradually contracting and leaving a smooth scar. Larger 
ulcers, dipping into the muscular coat, in the process of healing 
give rise to more or less extensive cicatrization and changes in 
the shape of the stomach ; thus, cicatrization near the pylorus 
is a frequent cause of stricture at that point and subsequent 
dilatation of the stomach, while the so-called girdle-ulcer may 
result in hour-glass contraction of the stomach. 

Pepper speaks of the process itself as a necrosis, and not a 
true ulceration. " The parts surrounding the ulcer are made up 
of broken-down red blood corpuscles, granular material and 
cells which stain but poorly, together with fibrine, hyaline 
masses and scattered red blood cells in the parts a little more 
removed. As the ulcer grows older, a small-celled infiltration 
takes place about it, showing a tendency to repair ; as healing 
takes place, fibrous tissue forms in the walls and floor, and, 
contracting, leaves a smooth, stellate, white scar, with the 
mucous membrane puckered about it." 

Perforation constitutes one of the dangers connected with 
simple ulcer. Fortunately, when located on the posterior wall, 
this is often prevented by adhesive peritonitis, by which the 
stomach is permanently attached to the pancreas or left lobe 
of the liver, possibly to the transverse colon, diaphragm or 
spleen. If located on the anterior wall, the possibility of such 
an adhesion being formed is much less ; hence, the danger here 
is correspondingly greater. If ulceration penetrates the organ 
to which the stomach has become attached, abscess-formation 
takes place, and parts of the liver, spleen and pancreas may be 
destroyed by an intraperitoneal abscess thus formed. Perfora- 
tion may take place into the pleura, lungs, pericardium or 
transverse colon ; less often into the gall-bladder and left ven- 
tricle or through the skin. Perforation directly into the peri- 
toneal cavity usually results in death from shock and peritoni- 



788 DISEASES OF THE DIGESTIVE ORGANS. 

tis. An opening through the posterior wall into the lesser 
peritoneum may cause a subphrenic pyopneumothorax. 

Symptoms. — Post mortem examinations constantly reveal 
the presence of gastric ulcers in cases where during life no 
symptoms pointing to serious stomach trouble were experi- 
enced. Again, a violent haemorrhage or a fatal perforation 
may be the first indication of the lesion. In other cases a long 
history of dyspepsia is rehearsed, without a single symptom 
especially characteristic of ulcer until some change in the pa- 
tient's condition suddenly reveals the true nature of the affec- 
tion. 

Pain, tenderness, haemorrhage and vomiting are the most 
striking symptoms of gastric ulcers. Pain probably is the 
most constant and characteristic of these. It varies in degree 
of intensity, from a slight gnawing distress in the stomach 
when empty, as in the night, greatly relieved by eating, to 
paroxysms of intense gastralgia. The latter are usually 
brought on by eating, especially by taking into the stomach 
sour, very cold or very hot substances. In some cases it occurs 
within ten or fifteen minutes after eating, in others not for two 
hours, or even longer. It is usually felt just below the xiphoid 
cartilage, and often radiates from a small circumscribed spot 
in that locality to the back and sides. It may be almost unen- 
durable, the sufferer finding some relief from bending forward, 
often from hard pressure, usually from rest. It may return at 
the same hour after eating, for days, weeks, even months, and 
then suddenly disappear for a long time, to recur upon some 
slight indiscretion in eating or from some aggravation of the 
local trouble. Symptoms of attendant gastritis are often 
noticed in connection with it. Hemorrhage occurs in prob- 
ably more than half of all the cases studied. It varies greatly 
in quantity, but usually is copious and consists of fresh, bright- 
red blood. If bleeding is slight, the blood may have undergone 
changes ; but such is the case rarely. Frequently the blood is 
expelled through the bowels, especially when the ulcer is duo- 
denal, and then its color is dark. Haemorrhage may take place 
simultaneously from both stomach and bowels. If the amount 
of blood lost is large, syncope may result, followed by a tem- 
porary cessation of bleeding, to be renewed in the greater num- 
ber of cases soon after the patient has revived ; or death may 



SIMPLE ULCER OF THE STOMACH. 789 

occur. These large haemorrhages at best leave the system 
much impoverished, and the probability of their recurrence at 
any time is a source of apprehension. Tenderness to touch or 
pressure is always present, but cannot be considered of equal 
importance with other symptoms, since many persons in good 
health are naturally very sensitive to pressure in the epigastric 
region. However, in cases of gastric ulcer this tenderness is 
almost always marked, being usually most pronounced at a 
small spot an inch, or two, below the ensiform cartilage. In 
examining a patient suspected of ulcer for this condition, great 
care should be exercised lest firm pressure upon the part result 
in rupture and perforation at the seat of the ulcer. Nausea and 
vomiting are not always present ; but when present, it takes 
place in about two, possibly three, hours after eating. The 
vomited matter contains much hydrochloric acid and shows 
only slight traces of fermentation. In some patients vomiting 
is very persistent. It is beyond doubt often directly due to the 
irritation of the ulcer by the food eaten. 

With these, there is usually considerable loss of weight ; in 
very bad cases the emaciation may be almost as extreme as in 
malignant disease. Anaemia is proportionate to the amount of 
blood lost and to the starvation endured ; in women it is 
likely to be associated with amenorrhoea. Depression of 
spirits, headache, great despondency, stubborn constipation 
and a host of minor ailments, due to incidental phases of mor- 
bid action, render life miserable. 

Perforation is said to occur in 6!/2 per cent, of all cases, and 
seems to be more frequent in women than in men. Usually 
fatal, recoveries nevertheless occur occasionally. It is an- 
nounced by hard pain in the epigastrium, rapidly extending 
into the abdomen ; but the pain may be referred to some more 
distant part. Rapidly increasing abdominal distension, with 
excessive sensitiveness to touch, small rapid pulse, cold sweat, 
Hippocratic countenance, shallow breathing, and other symp- 
toms of collapse, are followed by death. 

The course of simple ulcer is chronic, continuing progress- 
ively, sometimes with periods of improvement, more or less 
pronounced, for an indefinite length of time, often for a series 
of years. Throughout this course various complications may 
arise, of which the chief are chronic gastric catarrh, chronic 



790 DISEASES OF THE DIGESTIVE ORGANS. 

peritonitis, pylephlebitis, parotitis of a septic character, and 
even cancer. Cirrhosis and dilatation of the stomach may re- 
sult. 

Diagnosis. — It is not difficult to recognize gastric ulcer in the 
presence of its characteristic symptoms : pain, vomiting, haem- 
orrhage. In actual practice, however, cases are common in 
which the train of symptoms renders a diagnosis difficult and 
even impossible. 

Both gastralgia and ulcer have points of striking similarity, 
and symptoms which largely determine the differentiation be- 
tween them may be of relative rather than positive value. 
Both have relief of pain from eating, but this is much more pro- 
nounced in gastralgia, and the very reverse often obtains in 
ulcer. In gastralgia pressure affords relief; in ulcer it aggra- 
vates ; yet, the patient suffering from ulcer very commonly 
seeks a position in which he can make hard pressure upon the 
epigastrium. In gastralgia, however, the pain lacks that ele- 
ment of sickening intensity which belongs to ulceration; the 
cessation of the paroxysm brings with it rest ; and the history 
of the case shows hysterical, neuralgic and neurotic tendencies. 
In ulcer the pain is of the peculiar agonizing character referred 
to ; the cessation of the paroxysm leaves the patient suffering 
with dyspepsia and symptoms of gastric catarrh, and there is 
an absence of neurotic sy^mptoms. Furthermore, in ulceration 
nutrition is more seriously affected ; there is hyperacidity of 
the gastric juice, and a possibility^ of detecting the presence of 
pyloric thickening and evidence of gastric dilatation. If haem- 
atemesis occurs in connection with intense pain and vomiting, 
a diagnosis of ulcer of the stomach may usually be made. In- 
testinal haemorrhage, with gastralgia, is presumptive evidence 
of duodenal ulcer. 

Gall-stone colic is distinguished from gastric ulcer by the 
suddenness with which the paroxysm of pain appears and dis- 
appears, the location of the pain at the right side, the probable 
enlargement of liver and gallbladder, and possibly jaundice. 

Haemoptysis is distinguished from the haemorrhage of gastric 
ulcer in that the history of the case points to some affection of 
the lungs or heart ; the blood is coughed up, and the cough is 
caused by, or associated with, tickling in the throat; it is 
sometimes followed by nausea and vomiting from swallowing 



SIMPLE ULCER OF THE STOMACH. 791 

blood ; the blood is frothy, bright-red, alkaline, sometimes con- 
tains small clots and often admixtures of sputa. The haemor- 
rhage of ulcer of the stomach may have no history of any pre- 
vious trouble ; the blood is vomited up, and the vomiting 
usually is preceded by faintness, nausea, and some dizziness ; 
the blood is fresh, bright-red, acid, and often contains small 
particles of food ; quite frequently blood is also passed with 
the stools. 

Treatment. — Absolute rest in bed is essential. German prac- 
titioners recommend the application of moist compresses or 
warm fomentations to the epigastric region. 

A proper diet is of the last importance, since the exhausted 
condition of the patient indicates generous feeding, while yet 
there is great danger of provoking gastralgia and bleeding 
from mechanical or chemical irritation of the floor of the ulcer 
by the introduction of food into the stomach. 

Struempell for the first ten days allows nothing but milk, 
boullion, and in exceptional cases thoroughly softened bread or 
egg. The patient doing well, during the next ten days such 
soft food as brains of calves boiled, sweet-breads, broiled fowl, 
or flour gruel, are allowed; after ten days more, sirloin or 
steak, rare and tender, underdone roast veal, game or fish may 
be given. The diet of the first ten days must be resumed when- 
ever irritability of the stomach threatens to return. Artificial 
foods may be added to the dietary as dictated by the judgment 
of the physician. 

To overcome the hyperacidity of the gastric juice, the same 
authority recommends a solution of a tablespoonful of Carls- 
bad salts in a pint of warm water, to be taken in three or four 
divided doses during the forenoon and afternoon. 

Others advise exclusive feeding per rectum for the first week, 
or two, giving only a little cool water by the mouth to relieve 
the thirst. "A single cleansing enema is given once daily ; and at 
six-hours intervals a nutrient enema, six to eight ounces in bulk 
and composed of one or two raw eggs, an ounce of expressed beef- 
juice, and fully peptonized milk, is administered. Tolerance by 
the rectum is promoted by the addition to the enema of a few 
drops of laudanum. After one or two weeks, small quantities 
of milk at frequent intervals are given by the mouth, and the 
rectal alimentation is gradually diminished as that of the 



792 DISEASES OF THE DIGESTIVE ORGANS. 

stomach is increased. Pain usually ceases immediately on the 
cessation of gastric ingestion, and the loss of weight during a 
fortnight of rectal feeding is surprisingly small." 

If nausea and vomiting are excessive, feeding by the stomach 
must be stopped at once. Lavage often affords relief of this 
troublesome condition. If pain is excessive, the external use of 
hot or cold applications or of chloroform may relieve ; morphia 
may have to be given hypodermically, but the great danger 
hereof establishing a "habit" must be borne in mind. E. M. 
Hale prefers codeine, in doses of ^4 to V2 grain. 

Haemorrhage demands absolute quiet and the greatest care 
in feeding. Nothing but ice-cold milk, ice-cream and bits of ice 
should be given by the stomach. Ergotine in two-grain doses is 
useful. Stimulants are indicated when syncope threatens, but 
must be given per rectum. Perforation may demand the imme- 
diate performance of laparotomy. 

Therapeutics. — Argentum nitricum. Severe pain in a 
small circumscribed spot just below the xiphoid cartilage, ex- 
tending to a corresponding point in the spine ; pain extending 
from the stomach into the chest, shoulders, abdomen. Great 
aggravation from eating or drinking ; enlargement and pain in 
the liver.— Arsenicum album. Gnawing pain in the stomach, 
with great tenderness to pressure. Burning pain as from a live 
coal. Exceeding irritability of the stomach ; it retains neither 
food nor drink ; great burning thirst ; drinking is followed im- 
mediately by vomiting. Pain after eating or drinking, with 
deathly nausea and vomiting. Great anxiety ; fears he will 
die. — Bismuth. Pressure as from a load in one spot ; intracta- 
ble vomiting ; severe pressive, burning pain extending from the 
stomach through the bod}' to the spine. Relief from cold 
drinks ; when the stomach gets filled, vomiting of very large 
quantities.— Phosphorus. Fainting ; cold extremities ; severe 
pressure in the stomach after eating, with immediate vomiting; 
vomiting after drinking cold water, for which he has an intense 
craving. Intense gastralgia, as from knives. Burning heat in 
the stomach, extending to the back, with faint, empty feeling 
in the stomach and bowels.— Hydrastis. Great soreness and 
burning in the stomach ; hyperacidity ; nausea and empty 
eructations ; f aintness, goneness in the epigastrium ; frequent 
vomiting; jaundice; torpidity of the liver. — Kali bichromi- 



SIMPLE ULCER OF THE STOMACH. 793 

cum. Vomiting of bile, of pinkish, glairy fluid ; pressure and 
heaviness in the stomach after eating; vomiting of white 
mucus ; acidity of the stomach, with pressure and burning. — 
Uranium nitrate. Vomiting of food ; agonizing, burning pain 
in the stomach, with deep ulcerative soreness. 

Consult also the therapeutic hints under "Gastralgia." 

Hsematemesis. — Aconite is indicated by full, bounding, hard 
pulse, with great bodily heat, thirst, profuse sweat, cold sweat 
on the forehead and extremities. Sudden, severe pain in the 
stomach. — Argentum nitricum and Arsenicum are recognized 
by the pronounced character of their gastric symptoms ; the 
haemorrhage is dark, and may be from either bowels or 
stomach, or both.— Belladonna. Congestive fulness and 
throbbing in the stomach ; bounding, hard pulse ; vomiting of 
bright-red blood.— Cactus. Continuous sickness at the stom- 
ach ; cold sweat ; cold face, cold back, cold hands ; sense of con- 
striction about the cardiac and epigastric region. — Ferrum. 
Vomiting of bright-red blood, partly in lumps; pallor of the 
face; pulse full, excited; throbbing heat and burning in the 
stomach, with crampy pains. — Hamamelis. Vomiting of dark 
blood ; violent throbbing in the stomach, followed by fulness 
and gurgling in the abdomen and large, tar-like stools. — Ipe- 
cacuanha. Incessant and great nausea and vomiting, with 
faintness and throbbing at the pit of the stomach ; vomiting of 
bright-red blood or of a tar-like substance. Melaena. — Mille- 
folium. Profuse haemorrhage of thin, bright-red blood, often 
with chilliness. Resembles Aconite, but lacks its anxiety and 
keen restlessness.— Secale. Sudden, violent haemorrhage, ac- 
companied by terrible distress and burning pain in the stomach. 
Threatening collapse. Restlessness and coldness, but refuses to 
be covered.— Veratrum viride. Great vascular excitement. 
Dry, red stripe through the center of the tongue. Contractive 
pains in the stomach. 

Consult also: Arnica, Carbo yegetabilis, China, Crotalus, 
Lachesis, Stannum. 

It has been affirmed that Geranium maculatum, given in 
half-drachm doses, relieves when all other remedies failed. 



794 DISEASES OF THE DIGESTIVE ORGANS 



CANCER OF THE STOMACH. 

The essential cause of cancer in any part of the body is not 
understood. The stomach is especially prone to cancerous dis- 
ease, statistics showing that next to the uterus it is most fre- 
quently the seat of cancer in its primary form. It occurs some- 
what oftener in men than in women. It is essentially a disease 
of advanced years, three-fourths of all the cases occurring be- 
tween forty and seventy years of age, and more than thirty per 
cent, between fifty and sixty years of age. It is exceedingly rare 
in children. Heredity unquestionably constitutes a predisposing 
cause, although the correctness of this statement is not ad- 
mitted by all. The appearance of the disease in successive gen- 
erations is not an assertion, but a fact, and the readiness with 
which in some persons slight local injuries assume all the feat- 
ures of malignancy can only be explained upon the assumption 
of a hereditary predisposition. The entire question of the aeti- 
ological relation of other diseases of the stomach to cancer 
hinges upon this proposition. 

Morbid Anatomy.— Cancer of the stomach in the great ma- 
jority of cases is primary; it may be secondary, and then usu- 
ally follows cancer of the breast. 

Its favorite location is near the p3^orus. Welch, whose sta- 
tistics are recent and generally quoted, from an analysis of 
1,300 cases gives the following table: in the pyloric region, 
791 ; lesser curvature, 148 ; cardia, 104 ; posterior wall, 68 ; 
the whole of the greater part of the stomach, 61 ; multiple tu- 
mors, 45 j greater curvature, 34; anterior wall, 30; fundus, 
19. Waldeyer (1867) showed that cancer is an epithelial 
growth and that the varieties in density are largely due to the 
amount of connective tissue which constitutes the stroma of 
the growth. "The tendency of the present time is to regard 
cancer as an epithelial cell containing corpuscular elements 
which are parasites (protozoa) or degenerated protoplasm or 
granules. These corpuscular elements transmit or disseminate 
the disease. They take root and grow in the new soil, extend- 
ing like a living thing by continuity and contiguity of struct- 



CANCER OF THE STOMACH. 795 

The affection begins in the gastric mucous membrane, rap- 
idly involving the entire wall, extending in circumference and 
in depth and height. The cancer assumes various shapes and 
forms, as the broad, flat or cauliflower-like masses of soft can- 
cer projecting into the stomach, or the rings formed by the can- 
cerous growth especially in the neighborhood of the pylorus. 
Ulceration is a common feature of all forms, followed by break- 
ing-down of tissue and haemorrhage, more pronounced in the 
soft than in the hard varieties. The weight of the growth may 
result in considerable displacement of the stomach; the changes 
which are incidental to the development of the cancer necessar- 
ily affect its shape. Thus, if the cardiac end of the stomach is 
the seat of the cancer, constriction at that point naturally 
leads to wasting of the stomach with diminution in size, with 
probable dilatation above the lesion, i. e., in the oesophagus. 
In the same manner involvement of the pylorus, with stenosis 
at that point, must of necessity give rise to dilatation of the 
stomach. Adhesions frequently form, and these may be ex- 
tensive, usually to the colon, liver or abdominal walls. They 
are an efficient protection against the danger of perforation. 
Perforation is not uncommon ; it usually occurs into the colon ; 
very rarely into the pleura, lung or pericardium. If into the 
colon, it is usually followed by vomiting of faecal matter and 
the passage of undigested food in the stools. Brinton states 
that in 507 cases of cancer of the stomach collected by him per- 
foration into the peritonaeum occurred in seventeen. 

Of the varieties of cancer seen in the stomach, the scirrhous 
usually involves the pylorus, causing stenosis and, later, dila- 
tation of the stomach. It is hard, occurs in circumscribed tu- 
mors, or is diffuse, involving the entire stomach, causing thick- 
ening and hardness of the wall. It ulcerates superficially. 
Medullary cancer is soft, grows rapidly, involves all the coats, 
projects into the stomach in masses of various shape, is gray- 
ish-white in color, abundantly vascular, and ulcerates early. 
Cylindrical- celled epithelioma occurs in large, rather soft, irreg- 
ular masses, firmer at the edges. Often it contains cysts, filled 
with mucus. It tends to ulceration and forms metastases. 
The colloid variety is the least common. It involves all the 
coats of the stomach, giving rise to uniform infiltration and 
thickening, and often spreads to neighboring parts, as the 
peritonaeum. Its ulceration usually is superficial. 



796 DISEASES OF THE DIGESTIVE ORGANS. 

These forms are not always clearly defined, and they may co- 
exist or one form may assume the characteristics of another ; 
thus the cylindrical-celled epithelioma may undergo a colloid 
metamorphosis. 

While secondary cancer of the stomach is not frequent, pri- 
mary cancer of the stomach is very often followed by sec- 
ondary cancer in other parts of the body. Welch shows that 
out of 1574 cases of cancer of the stomach the lymphatics 
(chiefly those of the abdomen) were involved in 551 cases ; the 
liver in 475; the peritonaeum, omentum and intestines in 357; 
the pancreas in 122 ; pleura and lung in 98 ; the spleen in 26 ; 
the brain and meninges in 9. Osier mentions the occurrence 
in two cases under his observation of a metastatic growth at 
the navel and beneath the skin near the navel. 

Symptoms.— The general clinical history of cancer in its early 
stage is characterized bj' the absence of peculiar and striking 
symptoms. It is not exceedingly rare, especially among old 
people, to have death result from cancer of the stomach when 
the patient during life not only suffered little, if any, pain, but 
aside from slight indigestion and failure of strength and health 
— such as belong to old age — appeared well. 

The onset of the disease is almost always masked. There 
may be slight indigestion, with some gastric uneasiness after 
eating, eructations, loss of appetite, some nausea and vomit- 
ing, and failure of strength. After a time it is noticed that the 
patient looks thin in flesh, pallid or even anaemic, and that he is 
rather more feeble, as to strength, than his condition would 
seem to warrant- These symptoms rapidly increase. The 
anaemia becomes unmistakable, after a time intense. The symp- 
toms of indigestion, especially the vomiting, with pain in the 
stomach, have increased very much. The face is haggard, pros- 
tration very great, emaciation startling, and there is oedema 
about the ankles and legs. The bowels are constipated ; the 
vomitus shows the presence of dark, grumous blood ; urine is 
scanty ; the pulse feeble and rapid ; he has chills, followed by 
sweating; and with a constantly increasing prostration and 
ever progressing anaemia death finally ccmes from asthenia, 
sometimes preceded by coma. 

As stated, in the earlier stage there may be nothing to attract 
the attention of patient or observer. The symptoms may be 



CANCER OF THE STOMACH. 797 

those of dyspepsia or chronic gastric catarrh with rather early 
loss of flesh and strength. Later, however, special symptoms 
assume particular importance, and upon their recognition de- 
pends the recognition of the disease. Pain is usually present, 
even in the early stage. It may be epigastric, but as often in 
the shoulders, between the shoulder-blades, or in the hypochon- 
dria ; it cannot ever be considered indicative of the seat of the 
disease. It is not, as a rule, acute or sharp, but rather of a 
heavy, gnawing, cramp-like character. Sometimes it assumes 
the form of a neuralgia. I have seen two cases in which it ap- 
peared early and continued throughout. Aggravation from 
eating is common, but not so pronounced as in gastric ulcer. 
Remarkable freedom from pain is occasionally observed, usu- 
ally in patients of advanced years. 

Vomiting, also, is a constant symptom, growing worse as 
the case progresses. It varies much in different cases. It may 
be almost incessant or may come on in paroxysms. In ad- 
vanced cases it usually occurs several times each day. It is 
more marked when the seat of the cancer is at the orifices. If 
the cardiac orifice is involved, it takes place soon after eating ; 
if the growth is at the pylorus, it is delayed for two hours, or 
more. Dysphagia is liable to be present when the cardia is the 
seat of the cancer. When there is dilatation of the stomach, 
vomiting may occur at long intervals, of several days, the 
amount ejected being very large. If the seat of the cancer is at 
the fundus or at the anterior or posterior wall, there may be 
no vomiting. The vomitus consists of a dark-grayish, sour- 
smelling fluid, containing mucus, food and blood, which under 
the action of the gastric juice has turned dark. Exceptionally 
the vomitus is very offensive. Should the tumor break down, 
vomiting ceases in the larger number of cases. 

Haemorrhage is a common symptom. In the majority of 
cases it consists of oozing of blood from the ulcerating cancer- 
ous mass and has the well-known coffee-ground appearance. 
It is rarely copious save late in the course of the disease, when 
large amounts of blood are occasionally thrown up ; this more 
frequently occurs when the seat of the cancer is at the pylorus 
or lesser curvature. 

The absence of free hydrochloric acid in the gastric juice of 
the cancerous stomach is of sufficient practical importance to 



798 DISEASES OF THE DIGESTIVE ORGANS. 

merit careful attention. It is a condition not peculiar to cancer 
alone, for it also occurs in atrophy of the gastric mucous mem- 
brane and in chronic gastric catarrh, but it is none the less im- 
portant and valuable in doubtful cases. Lactic acid in the gas- 
tric juice is said to be strongly indicative of cancer. (Boas.) 
The presence of a firm, hard, nodular tumor can often be made 
out by palpation, and is a sign of very great value. It may be 
located in the epigastric region, or from the weight of the tu- 
mor or stomach may have been displaced downward or toward 
either side. Struempell cites a case in which the stomach, in a 
case of cancer at the pylorus, was found a hand's breath above 
the symphysis pubis. In many cases the character of the tumor 
prevents detection by palpation (as in the case of a diffuse in- 
filtration of the walls of the stomach or when the cancerous 
mass protrudes inward) ; in others the enlargement is con- 
cealed by the liver or ribs. Thus, a tumor situated at the car- 
dia, posterior wall or lesser curvature is practically beyond 
the reach of physical examination ; a tumor located at the py- 
lorus or anterior wall or on a considerable portion of the 
greater curvature can usually be detected. In conducting the 
examination the patient must be placed on the back, with the 
legs well drawn up, so as to relax the abdominal walls. It is 
advisable also to force the tumor down by directing the patient 
to make deep inspirations and by placing him for a time in the 
knee-elbow position. Dilatation of the stomach being present 
in many cases of pyloric involvement, the examination would 
be incomplete if made without reference to its signs. Secondary 
growths in the liver, lymphatics in groin and supraclavicular 
spaces must be made the objects of careful search. Percussion 
yields a muffled tympanitic sound. 

Anaemia appears early in the history of the case and prevails 
throughout. It is pronounced and progressive, with a lessen- 
ing of the number of the red blood-cells, quite frequently reach- 
ing fifty per cent., and usually leucocytosis, the ratio of white 
to red blood corpuscles, according to Welch, having in one case 
reached one to twenty. The anaemia is accompanied with pro- 
gressive wasting of flesh ; it eventually terminates in a pro- 
found cachexia, more marked in cancer of the stomach than in 
almost any other condition known. GBdema of the ankles and 
legs, sometimes general anasarca, prevails, with rapid and fee- 



CANCER OF THE STOMACH. 799 

ble pulse and constantly, increasing weakness. Occasionally 
there is palpitation of the heart and dyspnoea, resembling car- 
diac disease. 

While the temperature usually is normal, there are exceptions 
in which, when the disease has advanced, there is a rise reach- 
ing 102°, and more, maintained for a considerable period of 
time ; eventually the temperature drops again to normal and 
even subnormal. Chills, followed by sweating, are occasional 
features. The intellect generally is clear, but toward the close 
a low delirium, preceded by a state of irritability and restless- 
ness, is not infrequent, succeeded by coma (coma diaceticum), 
with or without dyspnoea, terminating in death. 

The complications liable to arise are either incidental to the 
progress of the disease — as chronic gastritis or dilatation of 
the stomach— or depend upon the appearance of secondary 
growths in other parts of the body. The liver very often suffers 
extensively, and jaundice is frequently seen. Peritonitis also is 
common, at times with ascites. Pleuritis, pyopneumothorax, 
pulmonary abscess, gangrene or oedema, thrombi, especially in 
the femoral or saphenous vein, and chronic nephritis are occa- 
sional complications. 

The duration of the disease is from eighteen months to two 
years. In the greater number of cases it is impossible to fix the 
time of its beginning. 

The prognosis is hopeless. 

Diagnosis. — The most reliable diagnostic signs are: the pres- 
ence of a tumor ; progressive anaemia ; rapid loss of flesh and 
strength even in the early stage ; the character of the vomitus ; 
the absence of free hydrochloric acid in the gastric juice. The 
following table, by Welch, is generally reproduced in recent 
works : 



GASTRIC CANCER. GASTRIC ULCER. 



Chronic catarrhal 
gastritis. 



1. Tumor is present 1. Tumor rare. 1. No tumor, 
in three-fourths of the 

cases. 

2. Rare under forty 2. May occur at any 2. May occur at any 
years of age. age after childhood. Over age. 

one-half of the cases 
under forty years of age. 

3. Average duration 3. Duration indefinite; 3. Duration indefinite, 
about one year, rarely may be for several years. 

over two years. 



800 



DISEASES OF THE DIGESTIVE ORGANS. 



4. Gastric haemorrhage 
frequent, but rarely pro- 
fuse ; most common in 
the cachectic stage. 



5. Vomiting often has 
the peculiarities of that 
of dilatation of the stom- 
ach. 

6. Free hydrochloric 
acid usually absent from 
the gastric contents in 
cancerous dilatation of 
the stomach. 

7. Cancerous frag- 
ments may be found in 
the washings from the 
stomach or in the vomit 
(rare) . 

8. Secondary cancers 
may be recognized in the 
liver, the peritonaeum, 
the lymphatic glands, 
and rarely in other parts 
of the body. 

9. Loss of flesh and 
strength and develop- 
ment of cachexia usually 
more marked and more 
rapid than in ulcer or in 
gastritis, and less expli- 
cable by the gastric 
symptoms. 

10. Epigastric pain 
is often more continuous, 
less dependent upon tak- 
ing food, less relieved by 
vomiting, and less local- 
ized than in ulcer. 

11. Causation not 
known. 



4. Gastric haemorrhage 
less frequent than in can- 
cer, but oftener profuse ; 
not uncommon when the 
general health is but little 
impaired. 

5. Vomiting rarely re- 
ferable to dilatation of 
the stomach, and then 
only in a late stage of 
the disease. 

6. Free hydrochloric 
acid usually present in the 
gastric contents. 



7. Absent. 



8. Absent. 



9. Cachectic appear- 
ance usually less marked 
and of later occurrence 
than in cancer, and more 
manifestly dependent 
upon the gastric disor- 
ders. 

10. Pain is often more 
paroxysmal, more influ- 
enced by taking food, 
oftener relieved by vom- 
iting, and more sharply 
localized than in cancer. 

11. Causation not 
known. 



4. Gastric haemorrhage 
rare. 



5. Vomiting may or 
may not be present. 



6. Free In-drochloric 
acid may be present or 
absent. 



7. Absent. 



Absent. 



9. When uncomplicat- 
ed, usually no appear- 
ance of cachexia. 



10. The pain or dis- 
tress induced by taking 
food is usually less severe 
than in cancer or ulcer. 
Fixed point of tenderness 
usually absent. 

11. Often referable to 
some known cause, such 
as abuse of alcohol, gor- 
mandizing and certain 
diseases, as phthisis, 
Bright's disease, cirrho- 
sis of the liver, etc. 



HEMORRHAGE FROM THE STOMACH. 801 

12. No improvement, 12. Sometimes a his- 12. May be a history 
or only temporary im- tory of one or more pre- of previous similar at- 
provement, in the course vious similar attacks, tacks. More amenable 
of the disease. The course may be irregu- to regulation of diet than 

lar and intermittent, is cancer. 
Usually marked improve- 
ment by regulation of 
diet. 

Treatment. — Treatment is limited to efforts to render the pa- 
tient as comfortable as possible and to sustain his strength ; 
thus life may be prolonged and rendered more endurable. The 
diet must be regulated as circumstances demand ; fresh milk 
and koumyss, especially the latter, are usually acceptable. Hy- 
drochloric acid, exhibited in minute doses, is for physiological 
reasons presumed a great help to digestion. Eructations of an 
acrid, irritating character require magnesia or bicarbonate of 
soda. Vomiting is usually controlled by opiates, ice, iced cham- 
pagne, kreosote, iodine, lavage. Pain, especially when it pre- 
vents sleep, may imperatively demand the use of opiates. Osier 
recommends of morphia one-eighth of a grain, combined with 
carbonate of soda (grs. 5) and bismuth (grs. 5 to 10). Haem- 
orrhage rarely demands treatment. Bits of ice may be swal- 
lowed and cold applications made to the epigastrium ; ergot or 
ergotine in physiological doses may be needed in exceptionally 
severe cases. Constipation is at times troublesome ; laxatives 
must be avoided, but enemata or glycerine suppositories may 
be prescribed. Lavage is not only useful to control vomiting, 
but is called for when there is dilatation, as in pyloric stenosis. 

Since Billroth first advised and practiced removal of the 
stomach for cancer, the operation has been performed several 
times, so far with satisfactory success in a very few cases only. 

Therapeutics. — The utmost that can be expected is a measure 
of relief from pain which at least lessens the necessity of con- 
stantly using opiates and a sustaining effect which prolongs life 
beyond the period usual in cancer. To obtain even these re- 
sults the totality of symptoms must be carefully noted and the 
remedy selected with painstaking observance of passing 
changes in the symptoms. Undoubtedly Arsenicum is of value 
here oftener than any other remedy. I have in a number of 
cases found the Iodide of arsenic, in the third decimal tritura- 
tion, capable of doing much good. It controls the gastric pain, 
51 



802 DISEASES OF THE DIGESTIVE ORGANS. 

aids digestion, exerts a favorable effect upon the anaemic condi- 
tion, lessens the utter prostration of the vital forces, and ap- 
pears to make its kindly influence felt in every direction. — 
Phosphorus is another remedy worthy of patient use. Its 
close relation to the stomach and liver, and its action upon the 
nervous system and blood, warrant the presumption that the 
claims made for it are not without foundation in fact. 

Hydrastis is credited with having cured scirrhous cancer of 
the stomach in which there was involvement of the subclavicu- 
lar lymphatic glands. A tablespoonful , twice a day was 
given of an infusion of four drachms of the bark in half- 
a-pint of water. — Condum is worthy of study on account 
of its gastric symptoms and its relation to scirrhous indura- 
tions and hardness of glandular enlargements. — Lachesis is 
considered of value by J. S. Mitchell when there is severe 
pain and haemorrhage. William Owens urges the use of 
Acetic acid in the first dilution, given at brief intervals, and 
cites at least one case successfully treated in which, from the 
symptoms related, a diagnosis of cancer appears to have been 
justified. 

HEMORRHAGE FROM THE STOMACH. 

Haemorrhage from the stomach (haematemesis, gastrorrha- 
gia) may result from any of the following : Local diseases of 
the stomach as a) cancer or ulcer ; b) diseases of the walls of 
the blood-vessels of the stomach (changes in the coats of the 
vessels; varicosis; miliary aneurism); c) active congestion, as 
in acute gastric catarrh. Passive congestion, the result of ob- 
struction in the portal system. This may be a) hepatic (cirrho- 
sis of the liver, thrombosis of the portal vein ; pressure any- 
where upon the portal vein or any of its branches, as from a 
tumor; in chronic disease of the heart or lungs) ; or b) splenic. 
The latter is infrequent. Traumatism, mechanical (blows, in- 
juries to the stomach from the presence in it of sharp, pointed 
foreign substances), chemical ; (corrosive substances, phos- 
phorus) or thermal (very hot liquids). Acute infectious dis- 
eases, characterized by toxic action of the specific ptomaines 
upon the blood. Here belong typhus, typhoid fever, yellow 
fever, relapsing fever, malaria, erysipelas, diphtheria, cholera, 



HEMORRHAGE FROM THE STOMACH. 803 

small-pox, scarlet fever, measles. Other constitutional diseases 
and states in which the integrity of the blood is affected, as 
haemophilia, purpura, scurvy, chlorosis, anaemia, cholaemia. 
Certain diseases of the nervous system, especially hysteria; also 
epilepsy and progressive paralysis of the insane. Haemorrhage 
without the stomach, emptying into the stomach and then 
ejected by vomiting. Here belong the swallowing of blood in 
post-nasal bleeding and in haemoptysis ; haemorrhage from the 
rupture of an abscess or blood-vessel in the oesophagus or duo- 
denum ; the swallowing of blood by an infant when nursing 
from a bleeding breast. Also causes not enumerated above, 
such as melarna neonatorum, rupture of an aneurism of the 
aorta or any of its branches into the stomach. 

In general practice, haemorrhage from gastric ulceration and 
from cirrhosis of the liver is of especial interest because of the 
relative frequency with which they occur. 

The symptoms which precede the vomiting are faintness, 
qualmishness, sickness at the stomach, perhaps with some head- 
ache and dizziness. Quite often the onset of the haemorrhage 
is sudden and unexpected. Anaemia is always present, accord- 
ing to the extent of the bleeding. Syncope is frequent, and 
fatal cases of it are on record in which there was no outward 
manifestation of the copious haemorrhage taking place within 
the stomach. 

If the haemorrhage is passive and insignificant, the blood ap- 
pears dark, is fully digested, sometimes clotted and even fetid ; 
it may be more or less mixed ' with substances which throw 
light upon the cause of the bleeding. The most dangerous 
forms of gastrorrhagia are those arising from ulcer, cirrhosis, 
or the bursting of an aneurism. 

The diagnosis is rarely difficult. For differentiation of haema- 
temesis from haemoptysis see the chapter on Simple Ulcer of the 
Stomach. 

If there is reason to presume that deception has been prac- 
ticed, as is often done by hysterics or malingerers, all the circum- 
stances surrounding the case must be considered ; it may even 
be wise to make chemical and microscopic tests to determine 
the actual presence of blood corpuscles in the vomitus. The 
first and specific cause of a haemorrhage and, if in the stomach, 
its exact seat are not always easily determined. Fatal bleeding 



804 DISEASES OF THE DIGESTIVE ORGANS. 

may occur from a local lesion so minute as to escape detection, 
while in other instances very serious haemorrhage may be due 
to diapedesis. 

Treatment.— Absolute rest is of the utmost importance. The 
patient's alarm must be quieted by perfect self-possession on 
part of the attendants and frequent words of encouragement 
by the physician. The salutary, reassuring effect of these can- 
not be overestimated. Bits of ice not only relieve the nausea 
and faintness, but are the best thing to be used for the bleed- 
ing ; ice ma} 7 be given ad libitum and a light ice-bag be applied 
to the stomach. If the bleeding is severe, the head of the pa- 
tient may be lowered and a ligature applied to the leg or arm, 
or both. The use of styptics is not advisable ; they irritats the 
stomach and do little, if anything, towards arresting the bleed- 
ing. If the physician feels bound to exhibit a haemostatic, 
gallic acid (grs. x) or alum are least objectionable. Ergot, in 
physiological doses, may be used when the bleeding occurs from 
quite small vessels ; it is of no service whatever when haemor- 
rhage takes place from large blood-vessels. Syncope, if passing, 
requires no attention, and may even aid in stopping the bleed- 
ing by lessening the force of the heart's action, thus increasing 
the possibility of a clot forming. Temporary elevation of the 
head is usually sufficient to bring the patient back to con- 
sciousness. 

Transfusion of blood has been largely displaced by the infu- 
sion of a saline solution (a drachm of sodium chloride to the 
pint of warm water). " Not over a half or three-quarters of a 
pint should be introduced at first. When a recurrence of the 
haemorrhage is feared, more can be used later, should the ur- 
gency of the symptoms again demand it. The solution should 
be made with boiled, preferably distilled, water. It must be of 
the body temperature and is readily introduced, all that is re- 
quired being a small glass canula, a piece of rubber tubing, and 
a funnel. The fluid might be injected into the cellular tissue, 
preferably between the scapulae, in place of a vein. The result- 
ing benefit would be as great, though not so promptly pro- 
duced, and the danger, that of sudden raising of vascular ten- 
sion, would be largely obviated." (D. D. Stewart in Hare's 
System of Therapeutics.) The injected solution may be dif- 
fused by massage. After the cessation of the haemorrhage the 



HAEMORRHAGE FROM THE STOMACH. 805 

patient must be kept in bed and absolute rest of the stomach 
be maintained for a considerable time by rectal feeding. When 
again allowed to eat, the patient must be closely watched, and 
food, carefully selected, must be given in small amounts only, 
cold, and in liquid form. 

Therapeutics.— Aconite. Acute congestion or inflammation 
of the gastric mucous membrane. Full, bounding, hard pulse. 
Great bodily heat, thirst, profuse sweat; cold sweat on the fore- 
head and extremities. Precordial anxiety, with coldness of 
the extremities. Excruciating pain in the stomach, with gag- 
ging and retching; fear of death. Haemorrhage preceded by 
sensation of a cold stone lying in the stomach, notwithstand- 
ing repeated stools and vomiting. — Arsenicum. Periodic haem- 
orrhage in cancer or ulcer of the stomach. Constant retching 
and nausea ; f aintness ; burning pain at the stomach, with in- 
tense thirst, with a feeling that cold water would relieve this 
burning; quick, thread-like pulse; characteristic anxiety and 
restlessness; blood dark and offensive.— Belladonna. Con- 
gestion ; sense of fulness and warmth in the stomach. The 
blood feels hot; usually bright-red.— Carbo vegetabilis. Col- 
lapse. Frequent fainting. Icy coldness of the surface and of 
extremities. Hippocratic face. Cold breath. Small, almost 
imperceptible, pulse. Wants to be fanned constantly and hard. 
Blood bright-red.— Cactus. Continuous sickness at the stom- 
ach. Coldness of face, back, hands. Cold sweating; sense of 
constriction about cardiac and epigastric region. — Ferrum. 
Vomiting of bright-red blood ; pallor of the face ; pulse full 
and excited ; throbbing, heat and burning in the stomach ; 
crampy pain.— Hamamelis. Fulness and pain precede the 
haemorrhage ; violent throbbing in the stomach ; vomiting of 
dark blood ; fulness and gurgling in the abdomen, followed by 
black, tar-like stools. Weak, quick pulse, with restlessness; 
cold, profuse sweat.— Ipecacuanha. Haemorrhage sudden, ac- 
companied with incessant nausea and much vomiting ; f aint- 
ness and anxiety ; blood bright-red ; sour; dark, like tar. Cold- 
ness and pallor of the face and body. Pulse scarcely percep- 
tible ; oppressed breathing ; great thirst.— Millefolium. Haem- 
orrhage profuse, thin, bright-red, often with chilliness. — Nux 
vomica. Throbbing pain in the head ; pale, distressed face ; 
belching ; constant nausea ; stomach full and distended, sore to 



806 DISEASES OF THE DIGESTIVE ORGANS. 

the touch ; burning anxiety and pressure in the precordial re- 
gion ; pain in the region of the spleen ; constipation, with black 
stools; urine turbid, dark; fainting ; weakness ; temperature of 
the skin increased; pulse full, hard, quick.— Phosphorus. 
Bright blood; drowsiness; sleepy; face, lips, gums and tongue 
are pale; thirsty, better from drinking cold water; loathing of 
food ; heaviness and heat at the pit of the stomach, which is 
distended ; abdomen soft ; urine dark ; skin warm, with partial 
perspiration; pulse quick, energetic— Secale. Passive bleed- 
ing; blood fluid, does not coagulate easily and is of offensive 
odor; great weakness, but no pain. Face, lips, tongue and 
hands deathly pale. Abdomen soft and cold ; cold sweat; quick, 
thread-like pulse; oppressed breathing. Or sudden haemor- 
rhage, violent and accompanied with great distress and burn- 
ing pain in the stomach. Threatened collapse, restlessness, cold- 
ness, but cannot bear to be covered. — Veratrum album. Slow 
pulse; ashen color of the face ; coldness of the skin; chilliness; 
fainting; thirst for cold drinks; any motion at once brings on 
nausea and fainting. Cold sweat.— Veratrum viride. Great 
vascular excitement. Dry, red stripe through the middle of the 
tongue. Contractive pain in the stomach. 

MISCELLANEOUS AFFECTIONS OF THE 
STOMACH. 

Stenosis of the cardiac orifice is a rare affection, exceptionally 
spasmodic, but oftener due to the presence of cicatricial con- 
tractions, ulceration, or scirrhous involvement of the oesopha- 
gus or of that portion of the stomach in the immediate vicinity 
of the cardiac orifice. Aneurism or tumor in closely related 
parts, or the presence of some foreign body in the oesophagus, 
or the local action of a violent corrosive poison, may produce 
stricture. 

The symptoms are fairly characteristic. There is difficulty or 
impossibility of swallowing food or drink. If there is not com- 
plete stenosis, liquids may be swallowed, though often only 
with considerable effort and choking ; if complete, nothing can 
pass the orifice. There is dilatation of the oesophagus above 
the stricture, forming a pouch in which food is indefinitely re- 
tained. It is regurgitated at frequent intervals if the oesopha- 



MISCELLANEOUS AFFECTIONS OF THE STOMACH. 807 

geal dilatation is not great, and then returns practically un- 
changed. If the dilatation is great, food may be retained for a 
long time, and when returned is fermented, covered with mu- 
cus, and highly offensive. Ulceration may exist, in which case 
the act of swallowing is very painful. Considerable discomfort 
and uneasiness is felt at all times. 

The appetite of the patient for a long time is unimpaired, and 
the difficulty of appeasing hunger gives rise to much and in- 
tense suffering. Emaciation and loss of strength naturally re- 
sult ; the general health breaks down ; the vital forces become 
exhausted ; a low fever sets in, dropsical effusion takes place in 
the lower extremities, and death finally occurs from starva- 
tion. 

The diagnosis is not difficult. The prognosis is unfavorable, 
save in the spasmodic form. Treatment is palliative and sup- 
porting. If the stricture is spasmodic, as is shown by the pass- 
ing of the bougie, feeding with the tube is indicated. If the 
bougie cannot be passed, nutritive enemata must be employed. 
Baths are useful in relieving the thirst from which the patient 
usually suffers ; bits of ice in the mouth may be allowed for the 
same purpose. Dilatation of the stricture and other, more rad- 
ical, operative measures are indicated. 

Stenosis of the pyloric orifice is the result of ulcerative pro- 
cesses at or near the pylorus ; or of cancerous disease ; or of 
fibroid thickening of the submucous tissues ; or of the pressure 
of a tumor (as of the gall-bladder) ; or of adhesions, such as 
may result from inflammation set up by some injury received 
or in the course of inflammatory processes involving the pylorus 
or the adjacent structures. The symptoms are those of dilata- 
tion of the stomach, which is produced by retention of the gas- 
tric contents that cannot pass through the pylorus into the 
duodenum. 

Lebert and others have described a hypertrophic stenosis of 
the pylorus which not only occurs in cancer, but has been no- 
ticed as an independent affection. It is practically a circum- 
scribed cirrhosis. 

Cirrhosis (sclerosis, fibroid induration) of the stomach is a 
rare disease, more frequent among women than among men, 
and largely confined to the middle-aged. In the early stage it 
consists of a cellular infiltration of the connective tissue, and is 



808 DISEASES OF THE DIGESTIVE ORGANS. 

generally understood to be a non-suppurative inflammation of 
the interstitial, connective and supporting tissues of the organ, 
not affecting those by which its proper physiological functions 
are performed. The microscope yields largely negative results, 
among them an absence of cancer cells. The structures are 
tough and cartilaginous; the stomach appears like a firm, 
smooth, round or oval tumor, with coats of dirty-grayish 
color and a cavity much smaller than normal. If divided with 
the knife, the walls do not collapse. 

The causes of cirrhosis of the stomach are not known. It 
may occur as a feature of the late stage of chronic gastric ca- 
tarrh, and has also been associated, without good cause, with 
alcoholism and traumatism. The symptoms are not charac- 
teristic. There is indigestion, with its attendant results, and in 
some cases gastralgia. Again the symptoms resemble perni- 
cious anaemia and even cancer. As the tumor increases, the 
gastric symptoms assume a more pronounced character, and 
there may be complete anorexia, with subsequent emaciation 
and progressive general physical weakness. Peritonitis not in- 
frequently occurs. Death usually takes place from peritonitis 
or dropsy. 

The diagnosis is difficult and rests largely upon the exclusion 
of other and similar diseases. From cancer it can hardly be dis- 
tinguished during life, save as the cachexia is less pronounced and 
haemorrhage of the stomach is wanting. Fenwick recommends 
distending the stomach in all doubtful cases by making the pa- 
tient drink freely of soda-water, by which means a strongly 
tympanitic sound, in case of hypertrophy, is obtained on per- 
cussion. The prognosis is bad ; the duration indefinite, the case 
usually continuing for several years. Treatment is unsatisfac- 
tory. The lessened capacity of the stomach demands the use of 
very nourishing, concentrated foods. In many cases severe 
pain is felt during the latter part of the illness, and copious 
draughts of hot water, as hot as the patient can bear, have 
proved grateful. 

Gastromalacia (self -digestion of the stomach, post-mortem 
softening) is now held to be simply a post-mortem self -diges- 
tion of the coats of the stomach, prevented during life b\^ the 
influence of the vital principle. The process is the same, on a 
larger scale, which during life and under appropriate circum- 
stances gives rise to the simple, peptic ulcer. 



MISCELLANEOUS AFFECTIONS OF THE STOMACH. 809 

Atrophy of the stomach occurs rarely as an independent affec- 
tion; it may be a feature of chronic gastric catarrh in its later 
stages; it is also secondary to cancer and cirrhosis of the stom- 
ach. Fenwick asserts that it is seen in cancer of the breast, and 
that this fact accounts for many otherwise inexplainable cases 
of death after successful operation for cancer. The same author- 
ity states that the atrophy of the gastric mucous membrane 
may be combined with inflammatory conditions of some of the 
other coats of the stomach, and then proves fatal by exhaus- 
tion of the patient ; or it occurs in cases which are usually 
classed as idiopathic anaemia, and is the result of degeneration, 
as shown after death. There exists a close relation between 
atrophy of the gastric mucous membrane and pernicious 
anaemia, and, as stated by Pepper, upon this combination of 
profound anaemia and digestive disturbance the diagnosis of 
such cases may be made. This applies, however, to those 
cases only in which the disturbance of digestion is well pro- 
nounced. 

The treatment is that of the late stage of chronic gastric ca- 
tarrh. 

Abscess in the wall of the stomach is a rare disease, with 
symptoms closely resembling a violent acute gastritis, rapidly 
progressing to great prostration, delirium, and a fatal termi- 
nation within a few days. It occurs in connection with cancer, 
pus finding its way into the walls of the stomach through the 
mucous membrane ; it is said that cases are occasionally seen in 
fibroid thickening of the wall. A form has been described in 
which the submucous tissue becomes the seat of general sup- 
puration, as mentioned in the article on Acute Gastric Catarrh. 

Albuminoid (waxy, lardaceous) disease of the stomach some- 
times appears in the course of chronic gastric catarrh, and is 
usually connected with similar changes in the liver, spleen and 
kidneys. It cannot be recognized during life. Examination 
after death shows a pale and bloodless condition of the mucous 
membrane, which gives a brownish-red reaction when treated 
with iodine. There is destruction of the epithelial cells, which 
are found to have been converted into an irregular, homoge- 
neous mass. 

Tubercle of the stomach is very rare. When found, it is often- 
est seen in the greater curvature and is associated with exten- 



810 DISEASES OF THE DIGESTIVE ORGANS. 

sive ulceration. Wilson Fox never saw it commence in the mu- 
cous membrane, but found perforation of the stomach from 
tubercles which commenced in the peritonaeum, passing from 
without inward. 

Perforation of the stomach is seen in connection with gastric 
ulcer and cancer, and has been discussed in the chapters devoted 
to them. It may also result from injury from without (a stab 
or thrust) or from within (some sharp, pointed foreign body in 
the stomach); but such cases are exceptional. If the perfora- 
tion is small, a circumscribed peritonitis, possibly with the for- 
mation of an abscess, results ; if large, it is followed by a vio- 
lent general peritonitis, with tendency to a fatal termination. 
The office of inflammatory adhesions in the prevention of per- 
foration has been pointed out. 

Rupture of the stomach in health is almost always due to 
external violence received when the organ is distended with 
food. If the gastric walls are diseased, a slight force may suf- 
fice to bring about rupture. It has been asserted that the ac- 
cident has resulted from overdistension with food or gas, but it 
probably was due to other causes. Ziemssen states that he saw 
it occur from distension depending upon fermentation in a 
stomach which was the seat of stricture resulting from the 
healing of a chronic ulcer ; the symptoms were those of collapse, 
followed by peritonitis. 



DISEASES OF THE INTESTINES. 

C4TARRHAL ENTERITIS-DIARRH(EA. 

The term "diarrhoea" as synonymous with catarrhal enteritis 
is incorrect in so far as diarrhoea is only a symptom which 
may be found when there is absolutely no catarrh of the intes- 
tinal mucous membrane (as in cases due to nervous or emo- 
tional influences) and which, on the other hand, may be lack- 
ing when catarrh is clearly pronounced. 

The disease is found in all climates and occurs at any age, 
with a preference for children. A predisposition to it is quite 
pronounced in some persons. One attack leaves a tendency to 
recurrences. 



DISEASES OF THE INTESTINES. 811 

Etiology. — Among the immediate causes of acute catarrhal 
enteritis the following may be enumerated: Errors of diet, over- 
eating or partaking of some indigestible article of food ; chil- 
dren readily fall into such errors unless carefully guarded, espe- 
cially during the fruit season. Idiosyncrasy is an active factor, 
many persons being unable to take certain articles of food— as 
ice-cream or strawberries— without bringing on a diarrhoea. 

Poisoning, due to the formation in the body of organic poi- 
sons which are the product of fermentation or decomposition 
of food (as milk), or from eating spoiled or poisoned canned 
food, or from the administration of irritating drugs, as mer- 
cury, arsenic, antimony, powerful drastics, etc. Sudden changes 
in weather, as a decided fall in temperature, particularly when 
the body is insufficiently protected, or a sudden chilling of the 
body when perspiring. Equally effective is great heat; chil- 
dren frequently suffer from it during the hot months of the 
year (summer diarrhoea). Changes in drinking water, even 
though the water may seem wholly free from injurious con- 
tents and proves entirely wholesome to persons accustomed to 
it. Changes in the constitution of the intestinal secretions. 
The bilious diarrhoea, so called, is an illustration in hand, the 
sudden influx into the intestine of a large amount of bile being 
responsible for the intestinal disturbance set up. Trauma, as a 
blow upon the abdomen, the presence of hard lumps of faecal 
matter in obstinate constipation, or even irritation from the 
presence of intestinal worms. Nervous influences, depending 
upon a sudden excitement, from fright or other powerful emo- 
tions, often cause a diarrhoea which, though lacking the true 
catarrhal element, yet symptomatically belong under this head. 
Hysterical people are prone to suffer thus, the symptoms not 
only yielding reluctantly, but cases not rarely assuming the 
chronic form. 

Among the secondary causes are classed: Extension of inflam- 
matory processes from adjacent parts (peritonitis, hernia, ul- 
cerations, tubercular or cancerous ; some writers mention here 
an extension of gonorrhoeal vaginitis to the intestine). Circu- 
latory disturbances, due to the engorgement of the portal ves- 
sels, as found in cirrhosis of the liver, chronic diseases of lungs 
and heart. Certain infectious diseases (cholera, dysentery, ty- 
phoid fever, pneumonia, pyaemia, septicaemia, tuberculosis). 



812 DISEASES OF THE DIGESTIVE ORGANS. 

Extensive burns of the skin. Affections associated with a pro- 
found cachexia (anaemia, cancer, Bright's disease, Addison's 
disease). 

Morbid Anatomy. — The pathological changes are those found 
elsewhere in catarrh of the mucous membrane, save that the in- 
testinal mucous membrane not only is but slightly hyperaemic, 
but in the majority of cases appears pale and covered with mu- 
cus ; intense hyperemia is exceptional. Cellular infiltration is 
common. Purulent products on the surface of the mucosa are 
seen in severe cases, with superficial erosions. The solitary and 
agminated follicles are greatly swollen, with erosions in the 
center (follicular ulceration). In cases of long standing, hy- 
perplasia of the connective tissue often exists, giving rise to 
thickening of the mucous membrane, which then presents a 
puffy, uneven appearance on the inner surface of the intestine. 
"Circumscribed hyperplasia of the connective tissue may actu- 
ally lead to the formation of polypi. If the orifices of Lieber- 
kuehn's follicles are stopped, we have a cystic degeneration of 
the follicles from the retention of the intestinal juices." On the 
other hand, and especially in the chronic diarrhoea of children, 
there may be atrophy of the mucous membrane, chiefly affect- 
ing the glandular structure, connective tissue gradually dis- 
placing the glands. This is most pronounced in the ileum and 
colon, and may involve the muscular coat. 

Acute Catarrhal Enteritis.— Symptoms : Diarrhoea, i. e. in- 
creased frequency of the stools, which are of an abnormally 
loose consistency, is the chief symptom. It is the result of in- 
creased peristalsis and of the presence of a large amount of 
fluid in the intestinal tract. The number of stools varies 
greatly, from three or four to twenty, or more, per day. In 
consistency they are watery or pappy, like thin gruel. The 
color ranges from a dirty grayish-white to yellow, yellowish- 
brown, green, sometimes blackish-brown, depending largely 
upon the amount of bile present. Occasionally there is slight 
admixture of blood and of flakes of yellow-brown mucus. Bits 
of undigested food may be carried along under the impulse of 
greatly excited peristaltic action (lienteric diarrhoea). The 
stools usually are alkaline in reaction and in amount out of all 
proportion to the food eaten. The microscope shows the pres- 
ence of a perfect host of bacteria, cylindrical epithelium, triple 



CATARRHAL ENTERITIS-DIARRHCEA. 813 

phosphates, cholesterine, fatty acids, occasionally pus-cells, 
muscular fibres, remnants of food, etc. 

Pain is almost always present, especially in cases due to er- 
rors of diet. It frequently is worse before the stool, and is usu- 
ally relieved by pressure upon the abdomen. It is paroxysmal, 
but sometimes almost continuous, and of a "colicky" char- 
acter. If there is involvement of the colon, tenesmus is present. 
Tympanitis of moderate degree is common, but the abdomen 
may be flat. Gurgling and rumbling noises in the abdomen 
(borborygmi) are due to the rapidity with which increased per- 
istaltic effort carries liquids and gas along the intestinal canal ; 
this abnormal peristalsis can be easily felt by placing the hand 
upon the abdomen. 

Loss of appetite and thirst are nearly always experienced. 
The tongue usually is dry and coated, there is little, if any, 
fever, the urine is scanty, high-colored, and rich in urates. In 
severe cases there is much vomiting, intense thirst, and consid- 
erable fever, with a temperature of 102°, or more. There is 
reason to suspect a complication of some sort if there is a con- 
tinuously high fever or a sudden and marked elevation of tem- 
perature. In very bad cases all the symptoms are intensified, 
especially the pain ; the excessive loss of the fluids of the body 
becomes a threatening feature, and collapse may occur. 

The duration is from two or three days to a week or ten days. 

Cholera morbus (cholera nostras, sporadic cholera) may be 
described as an intensely acute catarrh involving both the gas- 
tric and intestinal mucous membrane ; in all probability it is 
due to the absorption of some toxin from the intestinal canal. 
It occurs chiefly during the season of the year when the days 
are very hot and the nights cold. Its readiest victims are 
young persons and those suffering from nervous exhaustion. 
Errors in diet, drinking ice-water and taking cold are the prin- 
cipal direct causes. 

Symptoms. — Although sometimes preceded, for a short time, 
by general indisposition, with a sense of gastric discomfort and 
heaviness, the onset is more often sudden, usually awaking the 
patient from a sound sleep by nausea, vomiting and sense of 
distressing fulness throughout the abdomen. Vomiting is vio- 
lent from the start, consisting at first of the contents of the 
stomach, which are quickly ejected, then bilious, then watery 



814 DISEASES OF THE DIGESTIVE ORGANS. 

substance. Paroxysms of vomiting follow each other rapidly ; 
often vomiting is incessant. Purging occurs simultaneously or 
very soon after vomiting has begun. This also is violent, first 
faecal and offensive, then watery, whitish, odorless, or of faint 
mouse-like odor. The evacuations come with a gush, are copi- 
ous, choleraic and rapidly exhausting. Pain is severe, often 
constant, with aggravations before purging and momentary 
relief after stool. There is twitching and cramping of the mus- 
cles, especially of the calves of the leg, sometimes exceedingly 
painful. The patient complains of great thirst, and is anxious 
and restless to the last degree. Urine is scanty, high-colored, 
contains albumin, casts, much indican; occasionally it is sup- 
pressed. Pulse is weak and thread-like; the abdomen con- 
tracted ; exhaustion rapid and profound. The voice is weak, 
husky and of high pitch ; the tongue and breath are cold, and 
the body bathed in a cold, clammy sweat ; the countenance is 
hippocratic; surface temperature low, though the internal tem- 
perature may be elevated ; respiration becomes sighing, and col- 
lapse seems imminent. 

All these symptoms may develop rapidly, and in persons of 
feeble powers of resistance, or in the very young or quite old, 
death from collapse may take place within a few hours. In 
such cases vomiting and purging may suddenly cease and in- 
cessant hiccoughing take its place. Usually, however, the dan- 
ger passes off in a few hours, and convalescence is fully estab- 
lished within twenty-four or forty-eight hours. The patient 
rallies slowly from the extreme prostration, and may not re- 
cover his usual health for a week or two. In exceptional cases 
subacute intestinal catarrh remains for some time ; the devel- 
opment of a remittent fever of the typhoid t3^pe or of dysentery 
is among the possibilities. 

The diagnosis is not difficult, except as the affection closely 
resembles Asiatic cholera. The non-existence of cases cf Asiatic 
cholera and bacteriological tests will determine the question. 
Poisoning with antimony, arsenic and certain fungi closely re- 
sembles cholera morbus. 

Chronic catarrhal enteritis may result from repeated attacks 
of acute intestinal catarrh, brought on, in the majority of 
cases, by the continued operation of causes which are primarily 
responsible ; hence the frequency of the disease in camp and 



CATARRHAL ENTERITIS-DIARRHOEA. 815 

prisons. It also occurs in connection with any chronic lesion in 
the intestinal tract, as tubercular ulceration or cancer, and 
with chronic engorgement of the portal circulation, as in cir- 
rhosis of the liver, chronic disease of the heart or lungs ; it is 
often observed in diseases characterized by cachexia, as phthisis 
or chronic malarial poisoning. 

The pathological changes at first are those of an acute ca- 
tarrh ; later the walls of the affected portion of the intestines 
become thickened by hypertrophy, with narrowing of the 
lumen of the gut, which rarely may amount to stenosis. Dila- 
tation occasionally occurs. Mucous, serous and purulent secre- 
tions abound upon the diseased structure, depending upon the 
catarrhal irritation of the mucous membrane and the frequency 
of existing ulcerative processes. There is thickening of the mu- 
cosa and the formation of polypi and of cysts from the block- 
ing up of intestinal glands and the subsequent retention of in- 
testinal juices ; also occasional and marked thinning of the in- 
testinal wall and atrophy of the mucous membrane and 
glands. Ulceration of the lymphatic follicles, especially in the 
descending colon, results from necrosis ; the ulcers are conical 
and sharply defined, and spread in both diameter and depth 
until they approximate each other and give to the mucous 
membrane a honey-combed appearance. The primary ulcer has 
a diameter of one-tenth to one-fourth of an inch. By coalescing, 
large spots of ulceration are formed which may penetrate deep 
enough to cause perforation, which here, as in ulceration of the 
stomach, is often prevented by fixed inflammatory adhesion. 
Incidental cicatrization gives rise to contraction of tissue and 
may seriously lessen the lumen of the intestine. When the duo- 
denum is the seat of the chronic catarrh, this thickening of the 
coats may obstruct the entrance of bile and pancreatic juice 
into the intestine. The ileum and colon, less often the rectum, 
may be the seat of the disease. 

Symptoms.— The symptoms are: diarrhoea, with gastric and 
intestinal indigestion, accompanied with more or less uneasi- 
ness in the bowels, sometimes severe pain and constitutional 
effects of more or less severity, not infrequently sufficient to 
cause death ; these constitutional effects are chiefly due to innu- 
trition, weakness and general exhaustion. 

The diarrhoea is not as pronounced as in the acute form of ca- 



816 DISEASES OF THE DIGESTIVE ORGANS. 

tarrh, and in the majority of cases consists of from one to eight 
stools each day, of watery or pappy, semi-solid consistency, 
varying in color from a dirty-whitish gray to a dark brown, 
containing mucus, particles of fat, undigested food, sometimes 
streaks of blood, and in some cases dark blood which originated 
in the upper intestine. These stools may occur regularly in the 
morning, or just after eating, or at irregular hours. Often di- 
arrhoea alternates with constipation. There is considerable in- 
testinal flatulency and borborygmi, with much pain in the 
bowels, usually worse after eating and just before a stool; this 
is due to the accumulation of gases and to the local irritation, 
intensified during peristalsis and when the discharges pass over 
the sore surface. The presence of gastric catarrh in the ma- 
jority of cases is indicated by loss of appetite, bad taste in the 
mouth, weight in the stomach, eructations, heart-burn, etc. 
There is general indisposition and lack of energy, and an al- 
most characteristic tendency to despondency and hypochondri- 
asis. Impairment of nutrition is plainly shown in the appear- 
ance of the patient ; he moves slowly and without energy ; is 
pallid ; thin in flesh ; complains of palpitation of the heart and 
dyspnoea from slight exertion; has occasional spells of feverish- 
ness, without a perceptible rise of temperature save as in some 
instances the diurnal variations are very pronounced. The case 
thus progresses tediously, with periods of improvement fol- 
lowed by relapse. With continuance of the affection emacia- 
tion eventually becomes very great ; the fever is unmistakable ; 
there is local or general oedema, and death results from exhaus- 
tion, usually hastened by some intercurrent affection, as per- 
itonitis, bronchitis or pneumonia. 

In mild cases the diarrhoea may be very moderate or wholly 
wanting, or there may even be constipation ; the latter is 
largely due to the muscular atony of the intestinal wall at a 
time when increased peristalsis is in reality rendered necessary 
D3 r the presence of large amounts of sticky, tenacious, intesti- 
nal mucus which not only interferes with the processes of diges- 
tion and absorption, but also with the propulsion of the stool. 
Intestinal flatulenc3 T and pain are almost always present. 
Traces of pus in the stool are an indication of intestinal ulcera- 
tion, and must not be allowed to escape attention. 

The special or exclusive involvement of any one portion of 



CATARRHAL ENTERITIS-DIARRHG3A. 817 

the intestine cannot always be determined from the symptoms? 
and usually is a matter of slight practical importance. How- 
ever, when the seat of the catarrh is in the duodenum, there is 
jaundice, fatty stools and gastric catarrh. If in the colon, the 
stools are very large and the abdominal pain just before the 
stool very severe. If the rectum is involved, there is tenesmus 
and the stools contain mucus and muco-purulent matter. 

The coarse of the disease is tedious ; the prognosis must be 
guarded in case of children, aged people or persons debilitated 
from any cause. If recovery takes place, recurrences of diar- 
rhoea from slight indiscretions in diet are the rule. Complica- 
tions are manifold, as peritonitis, periproctitis, bronchitis, pleu- 
ritis, pneumonia. Statistics show that corneal ulceration oc- 
curs in connection with camp-diarrhcea. When the rectum is 
involved, haemorrhoids, prolapse of the rectum and rectal ec- 
zema are frequent. Persistent constipation, derangements of 
digestion and nutrition, and material lessening of the lumen of 
the intestine are liable to follow persistent chronic diarrhoea. 

Diagnosis of Catarrhal Enteritis. — From the standpoint of a 
precise diagnostician it is desirable to determine just what por- 
tion of the intestinal tract is affected, even though such knowl- 
edge may be of no great value in the management of the case. 
If the small intestine is the seat of the catarrh, the diarrhoea is 
less active, flatulency not quite so pronounced, pain is of a 
more intense colicky character, and the stools contain a less co- 
pious admixture of mucus, with a larger amount of undigested 
food. In duodenitis we find jaundice, fat in the stools, and 
symptoms of gastric catarrh. Jejunitis and ileitis cannot be 
positively distinguished by the symptoms. Involvement of the 
large intestines has less colicky pain, sometimes no pain ; when 
present, the character of the pain is more like that of dysen- 
tery, and there is tenesmus. The stools are more granular, 
pappy, soupy, not lienteric, often grayish in color, and contain 
mucus. Colitis is generally associated with ileitis. Proctitis is 
characterized by frequency of stools, with great soreness and 
burning at the anus, with tenesmus and spasmodic contraction 
of the sphincters. The stools contain mucus and blood. There 
is usually pain and tenderness on pressure in the left iliac re- 
gion. The rectum is sore and painful, as demonstrated by ma- 

52 



818 DISEASES OF THE DIGESTIVE ORGANS. 

nipulation. There may be loss of power of the sphincters, with 
resultant discharge of fluid. 

Taking intestinal catarrh as a whole, it can be recognized 
without difficulty. As pointed out, the resemblance of cholera 
nostras to Asiatic cholera is striking, but in a suspicious case 
bacteriological tests will establish the identity of the disease. 
Typhoid fever in its early stage can soon be recognized by the 
character of the fever and the appearance of the characteristic 
rose- colored spots. Peritonitis is much less painful, and the 
bowels are constipated. Dysentery is more violent, there is 
greater tenesmus, and the stools are much smaller. 

Treatment of Catarrhal Enteritis.— Rest in bed is indispensa- 
ble; in the great majority of cases total abstinence from food, 
with small pieces of ice to relieve thirst, is equally important. 
If the symptoms are due to the presence in the bowels of some 
offending substance, as unripe fruit or spoiled meat, it is the 
part of wisdom to insure its prompt expulsion by administer- 
ing a full dose of castor oil or some smart cathartic. When the 
stomach has recovered tone sufficiently to bear food, bland sub- 
stances only should be allowed, such as boiled milk, rice boiled 
very soft in milk, gruels made of barley' or oats, and peptonized 
foods. Coarse bread must be forbidden ; soft toast or Zwie- 
back, softened in hot milk, may be eaten. 

For the relief of pain, application to the abdomen of hot fo- 
mentations, mustard plasters or turpentine may be tried. 
Ginger, internally, often proves comforting. Morphia should 
not be administered save in extreme cases. Enemata of starch 
(2 ounces) and laudanum (20 drops) are soothing and harm- 
less. 

If there is duodenitis, counter-irritation over the right hypo- 
chondrium is advisable. Fatty foods and starch are prohib- 
ited. When the large intestine is involved, copious flushing of 
the bowel with warm water is excellent. In proctitis soothing 
local applications are almost indispensable. Suppositories of 
cocoa butter and extract of opium usually afford relief; injec- 
tions of starch and laudanum are equally helpful. The inser- 
tion into the rectum of small pieces of ice is recommended by 
some clinicians. 

In cholera morbus the question of diet does not come up for 
consideration until convalescence, and the food then allowed 



CATARRHAL ENTERITIS-DIARRHCEA. 819 

must, of course, be bland and easily digested. The most ur- 
gent demand will be for relief from pain, which is quickest met 
by the hypodermic use of morphine. In my experience, the in- 
ternal use of the homoeopathic remedy is frequently effective in 
affording early relief, but the propriety of using morphia here 
cannot well be ignored. The craving for water may be satisfied 
by holding small pieces of ice in the mouth. 

To avert collapse, the external use of heat is indicated, as in 
the form of poultices, fomentations or hot bottles to the sur- 
face of the body. Stimulants may be used when the stomach 
can bear them. The serious danger from the loss of fluids is 
met by copious injections of water into the bowels or, better, 
under the skin. 

Chronic intestinal catarrh demands the utmost care in the 
selection of a proper diet and rigid enforcement of dietetic rules 
laid down. Boiled milk is almost universally suitable and 
should always be given a faithful trial. Starch-foods are to be 
used with great moderation. The exhibition of pancreatic ex- 
tracts is advisable. Rest in bed is also of great importance. 
Osier relates a very tedious case cured by keeping the patient in 
bed and on a diet of milk and albumin water. Raw scraped 
beef, made palatable by mixing it with jelly, is highly valued 
by European practitioners, and often does excellently. If there 
is constipation, active cathartics must be scrupulously avoided 
and resort had to such waters as Hunyadi and Friedrichshalle. 

In severe cases the same general rules are operative, and the 
necessity of rest in bed and an indefinitely continued diet of 
boiled milk, raw scraped beef, etc., is evident. Sugar, starch 
and fat are prohibited. When there is pus in the stool, it is 
advisable to inject small amounts of water, not to exceed one 
ounce, to which may be added from one-half grain to one grain 
of either sulphate of zinc, nitrate of silver or acetate of lead. A 
larger amount is not readily retained. Directions already given 
concerning the local treatment of proctitis are applicable in 
chronic enteric catarrh; in addition, irrigation of the rectum 
with a one or two per cent, solution of salicylic acid or boracic 
acid may be advantageously practiced. In the chronic diar- 
rhoea with ulceration which follows dysentery Osier denies all 
merit of internal medication, urges a diet which leaves the 
smallest possible residue, and gives astringent enemata. "From 



820 DISEASES OF THE DIGESTIVE ORGANS. 

two to four pints of warm water containing from half a 
drachm to a drachm of nitrate of silver may be used. In giving 
large injections the patient should be in a dorsal position, with 
the hips elevated, and it is best to allow the injection to flow in 
gradually from a siphon bag. In this way the entire colon can 
be irrigated and the patient can retain the injection for some 
time. The silver injections may be very painful, but they are 
invaluable in all forms of ulcerative colitis. Acetate of lead, 
boracic acid, sulphate of copper, sulphate of zinc, and salicylic 
acid may be used in one per cent, solutions." 

Therapeutics. — In the acute intestinal enteritis consult: 
Aconite, ^Ethusa, Aloes, Antimonium crudum, Apis, Argen- 

TUM NITRICUM, ARSENIC, BELLADONNA, BRYONIA, CaLCAREA CAR- 

bonica, Carbo vegetabilis, Chamomilla, China, Colocyn- 
this, croton tiglium, dulcamara, helleborus, ipecacu- 
ANHA, Iris, Jalapa, Jatropha, Kreosote, Magnesia car- 
bonica, Mercurius corrosiyus, Mercurius sol. Hahn., Nux 
vomica, Phosphorus, Podophyllum, Pulsatilla, Rheum, 
Phosphoric acid, Taraxacum, Veratrum album. 

In the chronic form : the above list ; also Graphites, Lyco- 
poddjm, Phosphoric acid, Sulphur. In cholera morbus : Ar- 
senic, Camphor, Cuprum, Secale, Veratrum album, possibly 
Jatropha, Podophyllum. 

Aconite. Acute form; from cold, getting wet, chilled, over- 
heated, exposure to draught ; from violent paroxysm of anger 
or from fright. Stools watery, green like chopped herbs ; great 
heat in the distended abdomen.— ^Ethusa cynapdjm. Infantile 
diarrhoea, with forcible vomiting of milk as soon as swal- 
lowed ; the milk is curdled and cheesy. Exhaustion after vom- 
iting ; the child falls into a doze after vomiting, evidently from 
very weakness ; stools light-yellow or greenish, lienteric, thin 
and watery; abdomen tense and sensitive; pulse small; convul- 
sions. Summer diarrhoea ; diarrhoea of dentition. — Aloes. 
Pain and rumbling in the bowels before stool. Copious emis- 
sion of intestinal flatulence, preceded by colicky pains low 
down. "The patient does not have a proper sense of the accu- 
mulation of faecal matter in the rectum, and there is loss of 
power in the sphincter, so that the stool escapes easily, and 
when the desire for stool comes, the patient is scarcely able to 
attend to it" (T. F. Allen). Proctitis ; haemorrhoids. — Antimo- 



CATARRHAL ENTERITIS-DIARRHOEA. 821 

nium crudum. Gastric symptoms quite pronounced, though 
not intense ; from overfeeding or from errors of diet generally, 
especially milk which is too rich. Vomiting excited by eating 
or drinking. Tongue coated white, as though covered with 
skimmed-milk. Frequent vomiting, chiefly of undigested food 
or milk. No thirst; cutting pain before stool; ill-tempered. 
Profuse lienteric diarrhoea. Brought on by drinking bad, 
spoiled beer. — Apis. Of service in very bad, far advanced cases, 
in infants, with a preponderance of brain symptoms (grinding 
of teeth; sopor; cephalic cry, etc.) overshadowing all else; 
stools watery, greenish-yellow ; abdomen distended ; urine 
scanty.— Argentum nitricum. Especially useful in chronic 
cases. Diarrhoea even after slight excitement. Stools green, 
like spinach ; mucous ; fetid. Persistent flatulency and nervous 
irritability are always present, with enormous distension of the 
abdomen. — Arsenicum. Diarrhoea after very cold drinks, from 
eating ice-cream ; usually with symptoms of gastric catarrh. 
Characteristic restlessness and thirst, drinking often, but little 
at a time; drinking and eating provoke vomiting. Stools 
green, slimy, mucous ; watery ; dark-colored ; bloody ; offensive, 
like carrion ; painless ; acrid ; involuntary ; sometimes with 
burning in the anus and rectum. Rapid loss of strength, even 
though the severity of the attack does not seem to justify it. 
In severe attacks with rapidly progressing exhaustion, and in 
the late stages, when the condition of the patient justifies 
grave apprehension as to the results. Burning pain in the 
stomach and abdomen. Abdomen distended and painful; 
stools acrid, dark, grumous, offensive, of cadaverous odor; in- 
voluntary ; pulse quick and irregular ; characteristic fever, rest- 
lessness, thirst; thinks he will die. Face haggard, hippocratic; 
surface of the body hot and dry, burning or cold, but with a 
sense of internal burning heat. Worse after midnight. In the 
late stage of cholera morbus, with burning and cutting pain in 
stomach and abdomen, with intolerable restlessness, apprehen- 
sion, anguish. Superficial breathing ; weak, almost impercep- 
tible pulse; icy coldness of surface; sense of burning heat 
within. Lips and tongue dry, black, cracked, bleeding. Stools 
like rice-water ; profound prostration.— Belladonna. Charac- 
teristic tendency to congestion and delirium. Great disten- 
sion of the abdomen, with sensitiveness to touch, pressure or 



822 DISEASES OF THE DIGESTIVE ORGANS. 

jar. Stools [of green mucus, containing lumps like chalk. — 
Bryonia. In the bilious diarrhoea of hot weather. Tongue 
thickly coated white ; thirst for large quantities of water ; sore- 
ness and sensitiveness of the abdomen; stools bilious and in- 
tenseh* irritating ; diarrhoea alternating with constipation of 
large, hard, dry stools. Pressure in the stomach after eating, 
as from a heavy load or stone. Headache; irritability. Useful 
in the diarrhoea occurring when the days are very hot and the 
nights cold ; when there is a sudden dropping of temperature, 
as after a thunder-storm. In children when the stools are light, 
undigested, painless, preceded by slight colic— Calcarea car- 
bonica. Chronic diarrhoea and diarrhoea of dentition, espe- 
cially of fair-complexioned, fleshy children of lymphatic tem- 
perament, with characteristic constitutional indications. Ab- 
domen hard as a brick; distended; stools chalky, lienteric, 
white, sour, smelling like rotten eggs; first hard, then pasty, 
then liquid. Natural tendency toward chronicit}^, with emaci- 
ation.— Calcarea phosphorica. Chronic cases in infants and 
old people, with desire for indigestible things ; gastric catarrh ; 
p3 r rosis; uneasiness in the abdomen, especially about the navel, 
relieved by passing flatus. Stools offensive.— Camphor. Chol- 
era morbus. Attack very sudden, with tendency to collapse 
well marked from the start; vomiting and purging may be 
comparatively light or even wanting. Prostration excessive ; 
face pale, livid ; eyes sunken and fixed ; lips drawn up, exposing 
the teeth. During the season of the year when diarrhoeas are 
most common it is often possible to abort an attack by the 
prompt administration of a few drops of the saturated alco- 
holic solution of camphor.— Cuprum. In cholera. It covers the 
intense colic and cramps in the stomach and abdomen and the 
cramping of the muscles, especially in the calves of the legs. 
The stools are not large ; there is great desire for warm drinks 
and food, which are swallowed with a gurgling noise. The in- 
tensity of the pain and the cramps, extorting violent screams, 
are the most pointed indications.— Carbo vegetabilis. Given 
in large doses, it is often useful when there is much gastric and 
intestinal flatulency, with the feeling, on part of the patient, 
that this constitutes the chief trouble. Also valuable in the 
diarrhoea of low fevers, with symptoms of collapse. The stools 
are brown, yellow, slimy, involuntary. Here the high poten- 



CATARRHAL ENTERITIS-DIARRHCEA. 823 

cies must be given.— Chamomilla. Summer diarrhoea of chil- 
dren, including catarrh from eating indigestible food. The 
child is peevish and fretful and -wants to be carried constantly, 
evidently obtaining relief from it ; it cries all the time unless 
carried. Stools watery, greenish, like chopped or scrambled 
eggs, small, hot, frequent, excoriating, and smelling like rotten 
eggs. Colic before and during stool ; better after stool.— China. 
Diarrhoea with gastro-duodenal catarrh. Dyspepsia, with an- 
orexia ; cannot bear to think of anything to eat, with occa- 
sional craving for sour, pungent things and for stimulants. 
Feels dull, stupid, sleepy after eating; unequal to any exertion 
of body or mind. Gastric acidity and flatulence, with no relief 
from belching gas. Tongue coated thick yellow ; headache ; ab- 
dominal distension with constant rumbling of gas, without re- 
lief from the emission of flatus. Stools are undigested, occur 
soon after eating, and are of cadaverous odor. Diarrhoea from 
eating fruit; diarrhoea of debilitating diseases.— Colocynthis. 
Severe, griping, twisting colic, hard, pressive, intense, the pain 
shooting in various directions, making him double up, worse 
from hard pressure, better after stool. The diarrhoea is not so 
characteristic ; usually copious, yellow, frothy, worse from eat- 
ing or drinking.— Croton tiglium. Summer diarrhoea ; gush- 
ing, the stools escaping as though from a hydrant; yellow, 
dirty-green or brown. Diarrhoea of nursing infants ; worse 
after eating or drinking. — Dulcamara. Yellow, watery diar- 
rhoea, with tearing-cutting before stool, as after taking cold. 
Worse during cold, wet weather. "Stools mucous, green, 
changeable, of sour odor, with general dry heat of the skin." T. 
F. Allen.— Graphites. Not often indicated in the acute, but 
very useful in the chronic, form when there are large, consti- 
pated stools, covered with mucus. There is usually gastric ca- 
tarrh, with considerable pain in the lower abdomen, increased 
by eating. — Helleborus. Like Apis, of value chiefly in bad 
cases of infantile diarrhoea, rendered serious from cerebral in- 
volvement. There is distension of the abdomen, with gurgling 
in it as though water were poured from a bottle. The stools 
are jelly-like, looking like frog-spawn, often accompanied with 
tenesmus. Coldness of the face; cold, clammy sweating; pulse 
thread-like; boring of the head in the pillows ; sopor; suppres- 
sion of urine.— Ipecacuanha. Of great value in the diarrhoea 



824 DISEASES OF THE DIGESTIVE ORGANS. 

of children, especially in early fall, provoked by eating unripe 
fruit and vegetables. Constant sickness at the stomach and 
vomiting of green, jelly-like mucus. Stools grass-green, fer- 
mented. Griping colic— Iris versicolor. Stools profuse, thin, 
watery, bilious, corrosive. Great burning at the anus, as if on 
fire ; vomiting of excoriating, acrid fluid ; vomiting of sour milk 
in children. Severe cutting colic. — Jalapa. Chronic diarrhoea 
of six or eight stools per day; dark, offensive, like gruel, with 
much griping and some tenesmus.— Jatropha. Warmly recom- 
mended by T. F. Allen as an extremely valuable remedy, used 
too little, for profuse, gushing, watery diarrhoea, sometimes as- 
sociated with coldness of the body and unquenchable thirst, 
frequently with rumbling and gurgling in the abdomen, at times 
with vomiting of large amounts of albuminous-looking sub- 
stance. It closely resembles Veratrum album, but, as a rule, 
lacks the violent pain of that drug.— Kreosotum. Irritability 
of the stomach ; nausea and vomiting after eating, with sore- 
ness at the pit of the stomach. Persistent vomiting of infants. 
Stools undigested, dark -brown, offensive. Great restlessness. 
Diarrhoea of typhoid fever.— Magnesia carbonica. Infantile 
diarrhoea. Stools green and frothy, like the scum of a frog- 
pond. White masses like lumps of tallow float on the surface. 
Sour eructations and vomiting.— Mercurtus corrosivus. In 
proctitis, with pronounced dj^senteric symptoms. Not indi- 
cated save when there is intense inflammatoiy action or pha- 
gedenic ulceration. Violent burning pain in the abdomen, but 
especially in the rectum and anus ; stools frequent but small ; 
of mucus and blood, with oozing of excoriating ichorous fluid 
from the anus ; very great tenesmus ; lies on his back with knees 
drawn up ; small, irregular pulse ; cold, clammy perspiration. — 
Mercurdus sol. Hahn. (or Merc, vivus). Duodenitis. Abdo- 
men hard, distended ; great sensitiveness and soreness in the 
right hypochondria. Stools slimy, dark-green, acrid, bloody, 
with straining ; cutting pain, as though from knives, in the ab- 
domen. Tongue soft, flabby, coated whitish or yellowish. 
Jaundice.— Nux vomica. Diarrhoea alternating with constipa- 
tion ; from high-living, abuse of stimulants and irritating 
drugs. Constant and ineffectual urging to stool; severe sore, 
lame backache ; stools frequent, small, offensive, dark-colored. 
Feeling in the rectum as though "not done," after a stool. 



CATARRHAL ENTERITIS-DIARRHOEA. 825 

Bruised, sore pain in the rectum. — Phosphorus. Frequently of 
great value in the chronic form, or in diarrhoea associated with 
wasting disease or of cachectic origin, with much exhaustion of 
the vital forces and emaciation. The presence of little lumps 
like fat on the stool is one of its best indications. Watery, pain- 
less diarrhoea, usually worse in the morning after getting up ; 
sometimes it is gushing and copious ; or purulent, with oozing 
from the rectum.— Phosphoric acid. White, copious stool, 
painless, with considerable rumbling in the bowels. Its char- 
acteristic lies in the fact that the patient, though sick for some 
time, does not appear to lose flesh or strength. Very valuable 
in the treatment of painless summer diarrhoea during epidemics 
of cholera. — Podophyllum. Morning diarrhoea, from 3 to 9 
a. m. Painless, watery, with sediment like meal. Profuse, 
gushing, yellow, offensive ; stools change constantly in appear- 
ance. Duodenitis. Sometimes stool preceded by violent colic. 
In hot weather, during dentition. Camp diarrhoea. Prolapsus 
ani. The intensity with which Podophyllum acts justifies its 
exhibition even in cholera morbus.— Pulsatilla. Often useful 
in the milder forms of diarrhoea of women and children when 
there is gastric catarrh of a mild character, persistent, but not 
very severe, nausea and sometimes vomiting ; shifting pain in 
the abdomen, relieved by the external use of warmth ; constant 
change in color and character of the stools. Thought to be 
particularly indicated when resulting from eating indigestible 
rich food, as pastry, and from eating ices or drinking ice-water. 
The tongue is coated white ; there is loss of appetite ; regurgita- 
tion of food takes place a long time after eating. The entire 
process of digestion seems tardy and delayed. Children have 
colic about the navel, with evening aggravations and chilli- 
ness, nausea and vomiting. — Rheum. Not used as often as its 
merits warrant. Sour, liquid, slimy, green stools, like chopped 
eggs. Cannot bear to be uncovered ; feels worse if an arm or 
leg is uncovered. Sour sweating. (Soar-smelling diarrhoea, pre- 
ceded by colic; diarrhoea with colic and tenesmus, alternate 
chills, heat and thirst, with much (sour) sweating and weak- 
ness.— Secale. Cholera morbus. Watery diarrhoea, sudden in 
appearance, with vomiting, unquenchable thirst, suppression 
of urine, and collapse. Icy cold, but cannot bear to be covered. 
—Sulphur. Diarrhoea of thin, watery stools, usually fetid and 



826 DISEASES OF THE DIGESTIVE ORGANS. 

varying in appearance. Mucous diarrhoea, sometimes with 
streaks of blood ; imperative urging to stool ; child passes the 
stool in bed because it cannot get up quick enough. Offensive 
odor about the child ; the smell of the stool clings to it as 
though it had not been properly cleansed. Aversion to being 
washed. Of value chiefly in cases of a marked scrofulous dia- 
thesis, tending toward slow recovery and chronicity. The char- 
acteristic constitutional indications rather than the local symp- 
toms determine the choice of the remedy. — Taraxacum. A 
neglected remedy, freely and successfully used by the peasants 
of Germany in bilious diarrhoea, with bitter taste, heavily 
coated and mapped tongue, headache of a pressive character, 
with sense of soreness, shivering, and general malaise.— Vera- 
trum album. The violence of the pain and the simultaneous 
occurrence of vomiting and purging are its mo:t reliable indi- 
cations. Retching and vomiting are intense. The stools are 
very profuse, watery, sometimes blackish, and followed by ex- 
treme prostration. The pain in the abdomen is agonizing, us- 
ually beginning in the stomach and extending upward to the 
shoulders and downward involving the entire abdomen. Col- 
lapse. Of great value in cholera nostras. 

E. M. Hale calls attention to the usefulness of Gerandjm mac- 
ulatum ("a few drops of the tincture frequently repeated will 
cure chronic diarrhoea in a few days or weeks"), and to the 
root of Rubus villosus (blackberry) and Rubus Canadensis 
(dewberry), in doses of 10 to 20 drops of the tincture of the 
root. He also recommends Naphthalin (one-tenth of a grain 
to three grains) three times daily in chronic diarrhoea. 



ENTERITIS IK CHILDREN. 

The various forms of enteritis in infants and children corre- 
spond pathologicahV and symptomatically to similar lesions 
in the adult, but are sufficiently modified by the special envir- 
onments of infanc\' and early childhood to demand separate 
consideration. 

^Etiology.— In all cases errors of diet are important aetiolog- 
ical factors. These errors, though serious in their consequences, 
may at first glance appear trifling, but the sensitiveness of 



ENTERITIS IN CHILDREN. 827 

children and the comparative weakness of their digestion ren- 
der them very liable to derangements of the stomach and 
bowels. Thus, a thriving, breast-fed child of a healthy mother 
may quickly and severely suffer from changes effected in the 
mother's milk by a fit of anger which was passing and scarcely 
worthy of serious attention. Children artificially fed are pecu- 
liarly handicapped in that the articles which constitute their 
daily food are constantly liable to chemical changes and to in- 
fluences which render them poisonous rather than life-sustain- 
ing. A moment's consideration of the difficulty of securing 
cow's milk which answers every demand and of the repeated 
trials often necessary to determine the exact manner in which 
the individual infant can easily and fully assimilate it, is quite 
sufficient to prove this. And when there is added the almost 
impossibility during certain seasons of the year of maintaining 
the purity and freshness of this one article alone, it is readily 
understood why Holt's tables of 1943 fatal cases of enteritis in 
infants shows that 97 per cent, of these were artificially fed 
children. 

Children between six and eighteen months old are especially 
liable to enteritis; this applies particularly to infants whose 
surroundings are insanitary and who, through poverty and ig- 
norance of their parents, are neglected. The children of the 
well-to-do are by no means safe, but their chances to escape se- 
rious trouble are infinitely better. 

By far the larger number of cases of diarrhoea among infants 
and young children occur during the hot season of the year, be- 
ginning in May, growing worse in June, with a maximum of 
illness and mortality in July and August, materially lessened in 
September, and practically disappearing with the beginning of 
cold weather. To what extent the heat alone is responsible for 
this showing it is difficult to state, for children in the country, 
where the temperature may be quite as high, suffer very much 
less than do city children from this great danger to childlife. It 
must, however, be remembered that the heat of a city is espe- 
cially exhausting because there is in closely built large towns 
an absence of refreshing currents of air and of shaded, breezy 
places in which the country abounds. When we add to the 
state of depression resulting from this cause alone the general 
effects of that foulness and filth which prolonged summer heat 



828 DISEASES OF THE DIGESTIVE ORGANS. 

brings to all large places, and which are responsible for the an- 
nual exodus into the country and to the seashore of those who 
can afford such a luxury, we scarcely need the effects of toxin- 
laden milk to account for the lessons of the mortality tables. It 
is in view of these facts that the various charities which pro- 
vide for the infants of the poor a temporary home in some 
shaded farm house, or near the seashore or some lake, or daily 
trips on a river boat, in addition to pure, wholesome milk, have 
proved blessings to thousands of little ones who without them 
could not have escaped illness and death. 

Among predisposing causes special importance attaches to 
dentition, to feebleness of constitution and to inherited taints ; 
thus, scrofulous, rickety children, even amid the most favorable 
surroundings, are prone to the various forms of enteritis. Diar- 
rhoea of more or less severity also occurs in connection with in- 
fectious fevers and as the result of other exhausting diseases. 

Booker, Jeffries, and others, have studied the relation of bac- 
teria to enteritis of children, with the conclusion that "their ac- 
tion is manifested more in the alteration of the food and intes- 
tinal contents and in the production of injurious products than 
in a direct irritation upon the intestinal wall." 

Pathologically enteritis consists of hyperaemia and swelling 
of the intestinal mucous membrane, with enlargement of the 
lymph follicles ; in other forms, of follicular erosion and ulcera- 
tion ; more rarely of croupous inflammation of the lower ileum 
and colon. 

Clinically the following forms are recognized : acute dyspep- 
tic diarrhoea ; cholera infantum ; acute entero-colitis ; chronic 
diarrhoea. 

Acute dyspeptic diarrhoea is by far the most frequent of the 
summer diarrhoeas of infants. It is due to causes already 
enumerated. Errors in diet stand first in importance, and 
among them mention may be made of feeding infants miscella- 
neous articles which happen to be on the table, under the im- 
pression that "it will do them good;" in older children the affec- 
tion is often brought on by eating unripe fruit and vegetables 
or too freely of ripe fruit ; it also occurs at the onset of specific 
fevers of children. 

The symptoms are those of gastric and intestinal irritation of 
varying degrees of intensity. If the attack is light, there is 



ENTERITIS IN CHILDREN. 829 

moderate diarrhoea of rather offensive stools, containing curds 
of milk, but not in any sense characteristic, accompanied with 
some uneasiness and slight pain in the bowels ; little, if any, 
fever; the appetite is somewhat deranged, vomiting not at all 
or infrequent, and little thirst. The child may pass all night 
without having a movement, and its condition excites no uneasi- 
ness whatever. This continues for a few days, with gradual 
recovery, even without medical treatment. 

In the severe type the onset of the affection is sudden and vio- 
lent, with vomiting, diarrhoea and fever. The latter may be 
high, reaching 104°, or more ; when the fever is high, convul- 
sions are not uncommon. There is much colicky, griping pain, 
especially before stool ; the abdomen is distended, sensitive to 
pressure ; the child lies with its legs drawn up, evidently seek- 
ing relief from pain by relaxing the abdomen. The stools are 
grayish, greenish-yellow, sometimes sour and yeasty ; they con- 
tain curdled milk and particles of food if the child is old enough 
to take food other than milk. Mucus and slight tinges of blood 
are occasionally seen. Improvement and uneventful recovery 
usually take place in a few days. If complications arise, such 
as entero-colitis, or when the patient is of a constitution so en- 
feebled that he succumbs to slight causes, the case may termi- 
nate fatally. Relapses are common and not free from danger, 
since each successive attack not only weakens the child, but in- 
creases the tendency to a more serious form of intestinal affec- 
tion. 

Cholera infantum is much less frequent, but infinitely more 
dangerous, corresponding to the cholera nostras of adults. 
Holt states that it occurs in only two or three per cent, of all 
the cases of summer diarrhoea of infants. The causes are those 
of enteritis in children. It may follow cases of imperfect re- 
covery from acute dyspeptic enteritis. The chief symptoms 
are vomiting and purging, with early and profound exhaustion 
and pronounced tendency to collapse. 

The onset of the disease may be sudden or assume the form 
of an active diarrhoea, growing worse rapidly and associated 
at an early stage with vomiting. The vomiting, as in cholera 
morbus, is violent, almost incessant, and forbids taking either 
food or drink, which are ejected as soon as they reach the 
stomach. The stools are frequent and large, consisting at first 



830 DISEASES OF THE DIGESTIVE ORGANS. 

of faecal matter ; soon they become thin and watery, of brown- 
ish or 3 r ellow color ; later serous, like dirty water, and of alka- 
line reaction. At first they are offensive and they may remain 
exceeding^ foul throughout the course of the attack ; in other 
cases the3^ lose this foulness and become practically odorless. 
Great prostration is marked from the beginning and is unmis- 
takably expressed even in young infants. In the early stage 
there is aggressive restlessness and excitement; but this soon 
yields and the child falls into a semi-conscious, stupid state. 
The tongue at first is coated, and there usually is considerable 
fever, the thermometer showing a temperature several degrees 
higher in the rectum than in the axilla. The child suffers much 
from thirst, and greedily clings to any vessel containing water, 
but vomits as soon as a few drops are swallowed. The urine 
is scant3 T and the pulse rapid and full in the early stage, grow- 
ing weak and irregular as the case progresses. The appear- 
ance of the child is striking. The face is pinched ; the eyes lus- 
treless ; the f ontanelle sunken ; the surface of the body pale and 
cold ; it lies stupid, lifeless, with dry tongue, parched lips and 
scarcely perceptible pulse. 

A favorable turn of the case is indicated by lessening of the 
vomiting and diarrhoea and by the occurrence of lengthening 
periods of quiet, restful sleep. 

In fatal cases all these symptoms may develop with startling 
rapidity, and death may occur, usually preceded by a sharp rise 
of temperature, within twenty-four hours. In others, the vom- 
iting and diarrhoea cease, and the child passes into that condi- 
tion which Marshall-Hall described as "hydrencephaloid" or 
spurious hydrocephalus, the little one lying in an almost coma- 
tose condition, with clinched hands and fingers, sometimes gen- 
eral convulsions, head thrown back, with shallow, irregular, 
sighing breathing, suppressed urine, rolling of the head in the 
pillow, probably due to the constitutional action of the toxin 
absorbed from the intestine. 

The diagnosis of cholera infantum is easily made because the 
symptoms are unmistakable and characteristic. 

The prognosis is serious, and is rendered unfavorable by the 
presence of hyperp3^rexia, uncontrollable vomiting, and symp- 
toms of profound nervous prostration. 

Acute entero-colitis (follicular enteritis, follicular dysentery) is 



ENTERITIS IN CHILDREN. 831 

that form of diarrhoea which is so common and fatal in the 
second summer of child-life. It is rare after the third year has 
passed. It is seen as a complication of the specific fevers of 
childhood, and may follow an attack of dyspeptic diarrhoea or 
cholera infantum. 

The essential pathological features of the disease are swell- 
ing and softening of the affected mucosa, with enlargement of 
the solitary and agminated glands, terminating in erosion and 
ulceration of the follicles, which may enlarge and coalesce, giv- 
ing rise to sloughing which may involve the muscular structure 
of the intestinal wall. 

Symptoms. — Light cases present the symptoms of an acute 
dyspeptic enteritis in which almost imperceptibly the diarrhoea 
has changed to mucous, blood- streaked discharges, with a de- 
cided and nearly continuous elevation of temperature and an 
evidently unfavorable turn in the case. The stools are frequent, 
from ten to twenty or thirty in the twenty-four hours, small, 
acrid, offensive. There may be some intestinal uneasiness and 
even tenesmus, but often there is little pain or straining. Vom- 
iting at first may be pronounced, but usually ceases after a 
time. There is abdominal distension, with tenderness along the 
line of the colon. 

If the case is severe, the intestinal symptoms bear a close 
similarity to dysentery. The onset is sudden, with high fever 
and, possibly, convulsions. Vomiting, with diarrhoea which 
at first is fecal and offensive, then consists of small mucous 
and bloody stools, accompanied with straining and intense in- 
flammatory pain in the bowels and great prostration. The 
urine is scanty and rich in urates ; appetite is lost, nutrition 
impaired, and the general appearance of the child emaciated, 
haggard and worn. 

In the lighter form gradual improvement in the frequency of 
the stools and in the character of the diarrhoea and general 
condition of the patient lead to recovery in two or three weeks ; 
or the case becomes subacute, and then drags along for an in- 
definite period, slowly undermining even a strong constitution, 
terminating in eventual tedious recovery or death from exhaus- 
tion or some intercurrent malady. The severe form may prove 
rapidly fatal, but usually runs for a week, or two. 

The diagnosis rests upon the presence of mucus and blood in 



832 DISEASES OF THE DIGESTIVE ORGANS. 

the stool and the character of the fever, which distinguish this 
affection from acute dyspeptic enteritis and cholera infantum. 

The prognosis must be guarded. Recovery in even the milder 
forms is rarely prompt and complete, depending largely upon 
the age of the child, its previous history as to good health, 
habits and surroundings, and the manner in which it has been 
fed. Tendency to relapse is always great. 

Chronic diarrhoea of children. When a case of intestinal ca- 
tarrh has run for a period of six weeks, it is considered chronic; 
diarrhoea from tuberculosis is not here included. It is a fre- 
quent and serious affection, especially in children less than two 
years of age. It naturally divides itself into two types: the 
form in which the patholog3>- and symptoms are those of a 
purely catarrhal involvement, and the form in which are 
found the anatomical changes and symptoms of entero-colitis. 

The causes are : repeated attacks of intestinal catarrh ; per- 
sistent disregard of the rules which should be observed in feed- 
ing and of the laws of health generally ; inherited weakness of 
constitution ; predisposition and taint, as shown in the scrofu- 
lous or syphilitic taint and in rickety subjects. Age is of im- 
portance in so far as children less than two years of age fur- 
nish by far the greater number of cases. 

Symptoms. — The symptoms of chronic diarrhoea are chiefly 
those of gradual decline of the acuteness of an attack of enter- 
itis, with continued, but more moderate, diarrhoea, persistent 
innutrition, loss of flesh and strength, and undermining of the 
general health. Exceptionally the case may practically be 
chronic from the start, the symptoms at no time threatening 
danger from their severity, but rather from their unwillingness 
to yield to such methods of treatment as would usually be suc- 
cessful. 

The chief symptoms are: diarrhoea, innutrition, failure of 
general health. Symptoms of gastric catarrh, if present, are 
inconsiderable, and there may be an excellent appetite and en- 
tire absence of nausea and vomiting. The diarrhoea, after the 
case has become decidedly chronic, may consist of not more 
than four to six stools daily, of soft, mushy consistency, with 
every possible variety of coloring; but the frequency of stools 
varies, and may be great. At any time an acute exacerbation 
may result from exposure, or error in diet, or from relapse ; then 



ENTERITIS IN CHILDREN. 833 

the case at once assumes the characteristics which belong to 
that form of acute enteritis of which it is the chronic expression. 
During such intercurrent acute attacks the character and fre- 
quency of the stools at once changes materially. Almost 
always the ingestion of food is followed by increased peristal- 
sis and stool. Colicky pain of moderate severity and distension 
of the abdomen, with some flatulency and fever, may be pres- 
ent, but as a rule there is slight, if any, pain or fever after the 
case has become chronic. 

The constitutional symptoms which arise from innutrition 
are striking. There is constant loss in weight and strength ; the 
child becomes listless, pale, old-looking; the f ontanelle is sunken, 
the skin dry, wrinkled, harsh; the pulse rapid and weak; urine 
scanty. The child is fretful, peevish, irritable, restless both 
night and day, and often presents a pitiful picture of general 
wretchedness. 

The older the child and the greater its vitality, the lighter 
will be the symptoms and the greater the probability of even- 
tual recovery. 

The duration of the disease is indefinite, from a few months 
to a year. It is influenced largely by the judgment exercised in 
behalf of the child and by such outside conditions as the state 
of the weather, the presence or absence of extreme heat, and 
success in preventing exacerbations. 

But the prognosis is always serious, death usually occurring 
from exhaustion or from an intercurring acute attack of en- 
teritis or from some complication, as broncho-pneumonia. Of 
course, the longer and the more persistent the course, the more 
serious the outlook, particularly in children less than two years 
of age and of an inherited dyscrasia. 

Gee has described a form of diarrhoea in children which re- 
sembles the diarrhoea of tropical countries, and which he calls 
"the coeliac affection" (diarrhoea alba, seu chylosa). It is seen 
in children from one to five years of age, and is characterized 
by large, frothy, yeasty, exceedingly offensive stools of pale, 
whitish color, with doughy, inelastic abdomen, usually some 
flatulency, and progressive wasting, weakness and pallo 
rarely with fever. It begins insidiously, is lingering, and usu- 
ally fatal. It is not associated with tuberculosis or hereditary 
disease. 

Treatment of Enteritis in Children. — The successful treat- 
53 



834 DISEASES OF THE DIGESTIVE ORGANS. 

ment of all the forms of diarrhoea seen in infants depends quite 
as much upon close attention to hygienic and dietetic measures 
as upon intelligent medication. 

The very first care of the physician should be to insure to 
small children an abundance of pure, fresh air. Valuable as this 
is as a preventive, it is imperative when summer complaint has 
actually appeared. The little patient should at once be taken 
into the country, to the mountains, to the seashore— to any 
place where there is a generous supply of cool, fresh, pure air. 
The child should be kept in this ocean of health-giving, bracing 
atmosphere without reference to the convenience of others, to 
be taken in-doors only with the approach of night or when ren- 
dered necessary by the condition of the weather. There is no 
nobler charity than that which provides for this need of the 
children of the poor in large cities, whether by arranging for 
daily visits to a farm-house or for long-continued rides on a 
lake or river-steamer. When all these are beyond reach, a com- 
promise must be made by placing the sick child in a perambula- 
tor or baby-carriage of some sort, kept at a slow motion in the 
open air. This passive motion is not only harmless but di- 
rectly helpful, and if properly protected against the rays of the 
sun, the child will thus obtain rest which in the stifled tempera- 
ture of a close room and in the arms of a nurse would be out of 
question. 

Cleanliness in the fullest sense of the word gees far as a pre- 
ventive and aids wonderfully in the cure of diarrhoea. Refer- 
ence is made not only to the general habits of life, but to the 
various acts connected with the infant which are likely to be 
overlooked, even by mothers of average intelligence. Here, for 
instance, belongs the care of vessels in which the food is pre- 
pared or which are used in feeding the infant. A foul bottle or 
a dirty spoon may more than offset the best judgment used in 
the selection and preparation of the food. Another item is the 
proper care of the diapers, which should never be left in the sick- 
room or near the child, but should be removed as soon as 
soiled, and promptly washed. In fact, it is something more 
than a whim to insist that the nurse shall thoroughly disinfect 
her hands after changing the napkin or even wiping the sick 
baby. The diet certainly demands the utmost care. First of 
all we must remember that during the first twenty-four hours 



ENTERITIS IN CHILDREN. 835 

of an acute attack of enteritis all feeding had better be sus- 
pended, the patient being allowed nothing but water or a little 
toast-water. After that, the suitable diet having been selected, 
feeding must be had at stated times, every one to four hours, 
according to the age and needs of the child, taking pains to 
rather feed little at a time and often than to feed more gener- 
ously at longer intervals. A point almost equal in importance 
is to recognize at once the fact that very many of the prepared 
foods of trade, and especially the meat extracts, are of slight 
value when compared with the foods which are easily prepared 
at home. 

Since the vast majority of cases of diarrhoea occur in hand- 
fed children, the first symptoms of enteritis, usually of the dys- 
peptic form, must be the signal for a thorough inquiry into the 
diet of the little one and the correction of errors made. Even 
when breast-fed it is necessary to determine if the health of 
the mother or her present condition may not be responsible for 
the illness of the baby. If this is found to be the case, a wet- 
nurse should be provided, if one can be found possessing the 
necessary qualifications. When this cannot be done, the pa- 
tient must at once be put upon an artificial diet selected with 
reference to the special needs of the case. Escherich advises that 
albuminous foods be withheld and carbo-hydrates (dextrine, 
sugar and milk) be given when the stools are foul and offensive 
from decomposition ; and that an albuminous diet (egg-albu- 
men and meat-broths) be prescribed when there is acid fermen- 
tation with sour but not fetid stools. If milk is used, it should 
be carefully selected and sterilized ; in large cities a first-class 
brand of condensed milk or of malted milk is for many reasons 
the safest. But in nearly all cases it is wise to drop milk until 
the patient has recovered. 

Egg-albumen is easily prepared by beating the white-of -egg 
in a few tablespoonfuls of distilled water, adding a little salt 
and a few drops of brandy, if the latter is desired. Meat- 
broths must be prepared from day to day. Good lean steak, 
raw or slightly broiled, is finely chopped and the juice ex- 
pressed by means of a lemon-squeezer. This is heated and fed. 
Or a pound of lean mutton, chopped or minced, may be placed 
in a jar, covered with a pint of water; let it stand for three or 
four hours in a cool place, then boil slowly for three or four 



836 DISEASES OF THE DIGESTIVE ORGANS. 

hours, skim off the fat, add a little salt, and feed hot or cold. 
These are easily made, and much better than the prepared foods 
which flood the market. 

Drink may usually be given with considerable freedom, either 
of pure (distilled) water, or crust-coffee, or barley-water. 

When the diarrhoea is under control, the return to a milk-diet 
—sometimes milk-whey — must be gradual and cautious; the 
stools should be examined regularly, to determine if the diet 
agrees with the child. 

Throughout the attack it is advisable to use daily inunctions 
of olive oil or cod-liver oil. They are soothing, cleansing, and 
nourishing to an extent which is not generally appreciated. 

Hyperpyrexia at any time demands the use of a bath in 
water at a temperature of about 80° F., to which cold water 
may be added slowly in due time. Some practitioners by pref- 
erence use the wet pack, but for many reasons the bath, re- 
peated as often as may be necessary, is the better. Convulsions 
may demand the use of cloths wrung out of cool water applied 
to the head, changed frequently. Ice to the head is urged by 
some, but appears to me uncalled for and dangerous. 

In the treatment of cholera infantum the rules of diet and 
other general directions already given must be faithfully ob- 
served. If the temperature of the body is taken, the instru- 
ment must be used in the rectum. The loss of fluid, which here, 
as in cholera morbus, is an important consideration, may be 
met by copious irrigation of the stomach and intestine. Victor 
C. Vaughn insists upon repeated washing-out of stomach and 
intestine to free the S} r stem from the specific poison introduced 
by means of the milk eaten, which he considers the exclusive 
cause of this disease (''acute milk-infection"). "The bowels 
should be thoroughly irrigated with warm water and castile 
soap, not less than a gallon of water being used. After the 
large intestine has been cleansed in this manner, an injection 
of cool water, containing 15 to 30 grains of tannic acid to the 
pint, should immediately follow. Some of the poisons formed 
are, as we have seen, proteids which we have precipitated by 
tannic acid, but until the great mass of proteid in the large in- 
testine has been removed nc good can be expected from this 
agent. The object of the tannic acid irrigation is to render 
inert any soluble poisonous proteids which may remain in the 



ENTERITIS IN CHILDREN. 837 

intestines after the first washing. The stomach should be 
washed with warm water containing a teaspoonful of com- 
mon salt to the pint. After this organ has been thoroughly 
cleansed, from three to five grains of calomel should be admin- 
istered. These irrigations should be repeated as soon as the 
vomiting or purging returns. ***** After the vomiting 
has been allayed by irrigation, stimulants may be given by the 
mouth" (Starr's Amer. Text-book of Diseases' of Children). 
This treatment is based upon laboratory experiments rather 
than clinical experience. 

Small injections of starch and laudanum are serviceable. 

Entero-colitis requires the same general directions as to diet, 
consisting chiefly of broths, albumin-water, or yolk of tgg 
cooked for hours, until thoroughly mealy. Flushing of the rec- 
tum is exceedingly valuable, using for this purpose a small flex- 
ible catheter or rubber rectal tube connected with a fountain 
syringe. A large amount of water, from three to four quarts, 
should be used, to which may be added a few drachms of borax 
or hamamelis (1 to 10 of water). Cloths wrung out of hot 
water may be applied to the abdomen. Pepper strongly recom- 
mends enemata of clear water ; then medicate with "from 2 to 
6 ounces of a solution of tannic acid (5 grains to 1 ounce), ni- 
trate of silver (y 2 to 1 grain to 1 ounce), followed by a large 
enema of salt solution or by a mixture of bismuth in mucilage 
(V2 drachm to 1 ounce)." 

Chronic diarrhoea demands unremitting attention to diet and 
efforts to secure healthful surroundings. Peptonized foods may 
prove helpful, and if there is fat in the stools, pancreatin or 
pancrobolin may be used. Inunctions with oil and sponge- 
baths are of great value, but must be practiced systematically 
and perse veringly. 

Therapeutics.— For Acute Dyspeptic Enteritis: Aconite, 
^Ethusa, Antimon. crudum, Argentum nitric, Belladonna, 
Bismuth, Borax, Bryonia, Calcarea carbon., Chamomilla, 
China, Colocynthis, Croton tiglium, Ferrum phosphori- 
cum, gummi gutti, ipecacuanha, jalapa, jatropha, mag- 
NESIA carbonica, Phosphoric acid, Phosphorus, Podophyl- 
lum, Psorinum, Rheum. For Cholera Infantum: Aconite, 
^Ethusa, Apis, Arsenic, Belladonna, Bismuth, Calcarea 
phosphorica, Camphor, Croton, Cuprum, Gummi gutti, 



838 diseases of the digestive organs. 

Helleborus, Ipecacuanha, Jatropha, Podophyllum, Se- 
cale, Tabacum, Veratrum album. For Enter -o-colitis : Aco- 
nite, Aloes, Arsenic, Mercurius sol. Hahn., Phosphorus, 
Rhus toxicodendron. Vox Chronic Diarrhoea: Arsenic, Cal- 
carea carbonica, Calcarea phosphorica, Ferrum phosph., 
Iodine, Phosphorus, Psorinum, Sulphur. 
Consult also the list of remedies under "Enteritis." 
Aconite. At the beginning, with characteristic fever, rest- 
lessness, anxiety, thirst. Diarrhoea green, watery. Violent 
colic, as from inflammation. Choleraic discharges, with col- 
lapse and characteristic restlessness. — ^Ethusa cynapium. 
Violent vomiting of large chunks of curdled milk. Diarrhoea 
of curdled milk. Stools bilious, light-yellow, greenish. Spasms. 
— Aloes. Loss of power in the rectum ; flatulency ; diarrhoea 
of jelly-like lumps ; intense pain and soreness after stool. — An- 
timonium crudum. After nursing, vomiting of milk in little 
white curds; child refuses to nurse afterwards. Cannot bear 
to be touched or looked at. — Apis. Watery, yellow diarrhoea, 
sometimes painless. Stools dark, fetid, worse after eating. 
Chronic diarrhoea. Tenderness of the abdomen, even when it 
is not swollen. Stools involuntary, from every motion. Great 
stupor; refuses to eat or drink. Cholera infantum, with hydro- 
cephaloid symptoms. Suppression of urine.— Argentum nitri- 
cum. Stools green, mucous, like chopped spinach, usually with 
great flatulence ; of shreds of mucus and undigested food ; very 
offensive, with enormous distension of the abdomen and escape 
of much flatulence. Dysenteric stools, containing shreds of 
mucus. In children who are fond of sweet things, even during 
their sickness.— Arsenicum album. Gastric catarrh and irri- 
tability. Catarrhal enteritis. Diarrhoea accompanied with 
restlessness, thirst, vomiting, great prostration. Stools wa- 
tery, scant, dark, sometimes blood\^ ; followed by great exhaus- 
tion. Worse after midnight.— Belladonna. Much nausea and 
vomiting. Abdomen hot and sensitive to touch and jar. Dys- 
enteric stools, green and mixed with blood. Brain-S3^mptoms. 
Convulsions, with red, congested face; drowsiness, with starl- 
ings, dry heat and frequent vomiting.— Bismuth. Painless 
diarrhoea with great thirst; cholera infantum, with tongue 
thickly coated white ; cadaverously smelling stools. Vomits 
water, but retains food.— Borax. Offensive diarrhoea of 



ENTERITIS IN CHILDREN. 839 

nursing infants, preceded by colic; great dread of all downward 
motion or rocking; screaming before urinating; stools mucous; 
aphthous sore mouth. — Bryonia. Lips, mouth, throat dry ; 
very great thirst. Gastric irritability, with vomiting of food 
and sensitiveness to touch in the pit of the stomach. Summer 
diarrhoea, especially from errors in diet, children being allowed 
too much fruit and vegetables. Stools fascal, undigested, smell- 
ing like rotten cheese. Worse from motion.— Calcarea car- 
bonica. Child backward; malnutrition; flabby, weak, sluggish; 
profuse sweating; cold extremities; delayed dentition. Diar- 
rhoea of undigested food, copious, sour, fetid. Chronic diar- 
rhoea, with ravenous hunger, distension of the stomach and 
soreness to touch. Vomiting of milk in curdled lumps. Chol- 
era infantum. — Calcarea phosphoric a. "Cholera infantum, 
with great desire for undigestible things, like ham, smoked meats, 
etc. Abdomen sunken, flabby; emaciation; stools green, undi- 
gested, forcibly expelled" (T. F. Allen).— Camphor. Cholera 
infantum with collapse ; sudden and violent vomiting and diar- 
rhoea. Vomiting and diarrhoea suddenly ceases and the child 
lies almost unconscious, with blue hands and feet, etc.— Chamo- 
milla. Diarrhoea of dentition; stools green, slimy, mucous; 
mixed white and yellow, looking like scrambled eggs ; watery, 
undigested ; offensive, smelling like rotten eggs. Wants to be 
carried about all the time; keeps still only when being carried. 
Colicky pains, especially before stool.— China. Stools undi- 
gested, chocolate-colored, blackish, frothy, cadaverous ; worse 
every time the child is fed. Colic; distension and fermen- 
tation in the bowels; frequent emissions of fetid flatulency. 
Great weakness. — Colocynthis. Chiefly indicated by its se- 
vere griping, squeezing colic, with soreness in the abdomen, 
and frothy, yellow, liquid, slimy stools, containing undigested 
food, mucus and blood. Moderate tenesmus.— Croton tiglium. 
Yellow, watery stools, suddenly and forcibly expelled, with 
prompt aggravation from drink and food. Not always pain 
with the stool.— Cuprum. Violent spasms and cramps, draw- 
ing the flexors into visible knots. Stools watery, green, chol- 
eraic. After vomiting falls into an almost convulsive condi- 
tion. Coldness and blueness of the surface, with cold sweat 
and great prostration.— Ferrum phosphoricum. Cholera in- 
fantum. Fever; heat of the head, with red face; full soft pulse. 



840 DISEASES OF THE DIGESTIVE ORGANS. 

Stools watery, even bloody, undigested. Painless. Vomiting 
of food soon after eating. Debility. Chronic diarrhoea. — 
Gummi gutti. Stools thin, watery, yellow, faecal. Or dark- 
green, offensive, with mucus. Stool expelled all at once, with a 
single prolonged effort, followed by relief. Gurgling in the ab- 
domen as of a fluid running from a bottle. — Helleborus. 
Stools of pure white, jelly-like mucus, frequent, often involun- 
tary. Dark, scanty urine, with coffee-ground sediment. Skin 
cold and clammy ; boring of the head in the pillow ; automatic 
motion of one side of the body. In protracted and dangerous 
cases. Hydrencephaloid. — Ipecacuanha. Constant sickness 
at the stomach ; vomiting. Stools grass-green, fermented ; 
dark and fermented, frothy, looking like frothy molasses. 
Cholera infantum. Sleeps with eyes half open. Face pale. — 
Iodine. Chronic, exhausting diarrhoea. Stools watery, foamy, 
fatty, whey -like ; or mucous, bloody, fetid. Worse in the morn- 
ing and after drinking milk. Pale, yellow complexion. Will 
not allow anyone to come near him. Eats often and heartily, 
but continues to grow thin. Glandular enlargements. — 
Jalapa. Stools watery, sour; cutting colic; quiet all day, cries 
all night. — Jatropha. Cholera infantum. Profuse watery 
stools, gushing out like a torrent. Unquenchable thirst. Vom- 
iting of large quantities of watery, albuminous substances. 
Rumbling in the bowels, and noise as though a bottle of water 
were being emptied in the abdomen, not ceasing after stool. 
Cold, clammy perspiration.— Mercurtus sol. Hahn. Entero- 
colitis. Stools dark-green ; frothy; like chopped eggs ; watery, 
with greenish scum floating on the surface. Green, slimy 
stools, bloody. Undigested. Child seems to be ill at ease con- 
stantly, straining and fussing as though it could not get done. 
Appears to be in pain. Restless sleep. Sour-smelling night- 
sweat. Prolapsus recti. All the symptoms are intense. — Mag- 
nesia carbonica. "The bloody mucus is found mixed with the 
green watery stool, sinking to the bottom of the vessel and ad- 
hering there, but the watery stool remains alone" (Bell). — 
Phosphorus. Chronic diarrhoea with '-little grains like tallow" 
in the stool. Stools white, watery, gushing, of bloody water 
like the washings of beef. Liquid stool, green, bloody, oozing 
from the open anus. Involuntary, undigested stool. Pain- 
less diarrhoea. Thirst for cold drinks, with vomiting as soon 



ENTERITIS IN CHILDREN. 841 

as they have turned warm in the stomach.— Phosphoric acid. 
Copious white or yellow watery stools, painless, and without 
loss of flesh or exhaustion.— Podophyllum. Very changeable 
diarrhoea, gushing, painless, worse in the morning. Watery, 
with meal-like sediment. Chalk-like ; faecal ; frothy. Yellow 
mucous stool, offensive like carrion. Worse during hot weather, 
after eating milk, during dentition. Prolapsus ani. — Psorinum. 
Stools dark-brown, thin, fetid ; very offensive, almost worse 
than carrion. During dentition. Canine hunger. Great de- 
bility. Skin looks dirty, greasy, and the child smells foul even 
though well cared for. — Rheum. Stool, sweat, and entire child 
smell sour. During dentition and hot weather.— Rhus toxico- 
dendron. Putrid, slimy diarrhoea, sometimes involuntary. 
Child restless, hot. Stools of jelly-like mucus, transparent, of 
bloody water, like the washings of beef. Involuntary at night 
when sleeping. Pale, sunken face; putrid smell from the 
mouth. Tongue dry and rough, with red tip and edges.— Se- 
cale. Stools colorless, watery, slimy or dark-green, offensive. 
Gushing, involuntary. Intense thirst. Vomiting immediately 
after eating. Skin cold, blue, clammy, shrivelled; icy coldness 
of tha extremities ; in spite of being so cold, he cannot bear to 
be covered. — Sulphur. Scrofulous diathesis. Valuable as an 
intercurrent. In chronic cases. "Stools generally thin, watery, 
sometimes mucous, white or green, sometimes with bloody 
streaks, sometimes undigested, generally very fetid ; nearly al- 
ways worse early in the morning in bed" — Allen. Excoriations 
about the anus and genitals. Offensive odor about the body in 
spite of frequent washing. Great prostration and rapid ema- 
ciation. — Tabacum. Cholera infantum. Stools yellowish, 
greenish, slimy. Tenesmus. Collapse. Icy coldness of the leg 
below the knee. Warmth of the body, with icy cold hands. 
Feeble, irregular pulse.— Veratrum album. . Cholera. Sudden 
attack of violent vomiting and purging. Intense colic. Stools 
are profuse and watery, bilious, green. Rumbling in the 
bowels. Cold sweat on the forehead. Violent thirst. Vomit- 
ing worse from drinking, with violent retraction of the abdomen 
when vomiting. Voice husky and feeble. Breath cold. Great 
weakness. Suppression of urine. Skin of fingers and hands 
wrinkled and cold. Skin cold and blue. Collapse. 



842 DISEASES OF THE DIGESTIVE ORGANS. 



APPENDICITIS. 

Appendicitis or inflammation of the vermiform appendix is 
an affection which until recently was not recognized, but now 
ranks as a rather frequent and clinically very important disease 
of the intestine. The term is intended to cover pathological con- 
ditions formerly described under the names typhlitis, perityph- 
litis and extra-peritoneal abscess of the right ileac fossa. 

It is a disease chiefly of youth, by far the larger number of 
cases— about 60 per cent. — occurring between the sixteenth and 
thirtieth year of age. According to American statistics the 
number of men who have appendicitis is greater than that of 
women ; European statistics rather show the reverse. Occupa- 
tion is an aetiological factor in so far as persons who are 
obliged to lift heavy weights or whose employment involves 
exposure to blows on the abdomen or to similar injuries 
(trauma), are quite liable to it. The most important cause un- 
doubtedly is the entrance into the appendix, and the retention 
there, of faecal matter which eventually forms concretions of 
stony hardness (enteroliths, coproliths), setting up inflamma- 
tion ; these faecal concretions in shape and hardness resemble 
date-stones. Local irritation from other causes, notably the 
ingestion of indigestible, irritating food (as peanuts) or foreign 
bodies (as pieces of bone, seeds of grapes or raisins, or pits of 
cherries), is responsible for many cases. Ulcerative processes 
connected with typhoid fever or tuberculosis may attack the 
appendix, as other structures. In the relapsing form of appen- 
dicitis slight indiscretion in eating may prove sufficient to bring 
on a violent attack. 

Morbid Anatomy. — Cases of appendicitis may be divided into 
two classes: those which stop short of ulceration and those 
which go on to ulceration with its usual and dangerous conse- 
quences. 

In the lighter form of catarrhal appendicitis there is shedding 
of the epithelium and infiltration into the mucosa; when more 
severe, all the coats are thickened, the mucous membrane de- 
nuded and covered with granulation tissue. Circumscribed 
patches of peritoneal inflammation with adhesions may, or 
may not, exist. The thickening of all the coats of the appen- 



APPENDICITIS. 843 

dix, including the muscular coat, renders the tube firm and 
hard, like a finger or sausage. If pressure from without now 
brings into contact the opposing granulated surfaces, firm ad- 
hesions form and obliteration of the tube results, with im- 
munity from further trouble ( ohliterative appendicitis) . Exces- 
sive stiffness of the walls may, however, render them so un- 
yielding as to effectively prevent the approximation of the 
granulated surfaces ; if so, there is a chronic appendicitis with 
recurring exaggerations of all the symptoms. A stricture of 
the tube at the caecal end is liable to result in dilatation above, 
constituting a cyst, which contains clear fluid or pus. Catar- 
rhal or obliterative appendicitis may terminate in resolution or 
ulceration. 

Ulceration of the appendix may be due to typhoid or tuber- 
culous processes, to the presence of faecal matter or other for- 
eign bodies, or to the action of micro-organisms. Faecal con- 
cretions or foreign bodies do not necessarily cause local inflam- 
mation ; they have been found after death, with entire absence 
of local disturbance or only an atrophy of the mucous mem- 
brane upon which they were pressing. In other instances they 
undoubtedly excite inflammatory action leading to ulceration. 

Perforation may, or may not, follow ulceration. Cicatriza- 
tion may take place, greatly changing the shape of the appen- 
dix, even completely obliterating it. Or necrosis of tissue and 
sloughing may occur at the seat of the ulceration, preferably 
the tip, involving a more or less extensive portion of the appen- 
dix, followed by perforation. Or the entire appendix may 
slough off the caecum, without perforation. 

Efforts to determine the specific cause of Acute infective ap- 
pendicitis have led to the conclusion that the presence of bacilli 
(bacillus coli communis, streptococcus pyogenes, strept. pyog. 
aureus, and others), especially of the streptococci, is intimately 
connected with the infection, but that an important additional 
factor is found in the feeble powers of resistance which the ap- 
pendix, as a "degenerate and functionless organ" (Hawkins), 
offers to the bacterial invasion. 

Adhesive inflammation constitutes a very important part of 
the ulcerative process going on, since in many cases it confines 
the abscess within narrow limitations (intra-peritoneal ab- 
scess). The situation of the in tra-peritoneal abscess differs. It 



844 DISEASES OF THE DIGESTIVE ORGANS. 

is more commonly found on the psoas muscle, at the angle be- 
tween the ileum and caecum, or in the ileac region, between the 
navel and the anterior superior spine. It differs greatly in size, 
and contains yellow, thick pus, usually of faecal odor, which in 
the old and limited abscess may be dark and indescribably 
offensive. The intra-peritoneal abscess does not give rise to im- 
mediate serious symptoms and, if small, may end in resolution. 

Extra-peritoneal abscess usually terminates in the extensive 
formation of pus, with openings into the intestine, bladder or 
other parts, as the pleura ; even here recovery may follow. A 
retro-peritoneal abscess, usually extending downward toward 
Poupart's ligament or upward toward the kidney, occurs in 
case the appendix is posteriorly situated. 

Acute general peritonitis may result from rupture into the 
peritoneal cavity or from extension of the inflammatory pro- 
cess. It is always serious, but particularly so in cases of acute 
infective appendicitis characterized by the presence of the strep- 
tococcus pyogenes. Haemorrhages from destruction of the 
coats of an artery (internal ileac, deep circumflex ileac) and 
inflammation of the mesenteric veins with suppurative phlebi- 
tis may arise in the course of the extensive suppuration. 

Symptoms. — It has been asserted that in a young person, es- 
pecially after indiscretion in diet or after the receipt of an in- 
jury in the abdomen, as from a blow or a fall, the appearance 
of sudden pain in the abdomen (particularly in the right ileac 
fossa), of moderate fever, tenderness in the region of the ap- 
pendix, with nausea, vomiting and constipation, almost surely 
indicates appendicitis. This statement, made upon good 
authority, seems borne out by facts. 

Pain is a common and early symptom. It is present in about 
85 per cent, of all cases, and is sharp, cutting, like colic, or con- 
sists of a dull, heavy ache. Its favorite seat is the right ileac 
fossa, but it may occur at almost any other point in the abdo- 
men, according to the location of the appendix. It often shoots 
downward into the perinaeum or testicle and is aggravated by 
any movement of the body or from slight pressure, compelling 
the patient to bend forward and toward the right when walk- 
ing or, if in bed, to lie with the right leg drawn up. 

Fever with rise of temperature, appearing almost at once 
with the first sensation of pain, is highly characteristic, so much 



APPENDICITIS. 845 

so that the absence of fever with pain in the abdomen throws 
doubt upon a diagnosis of appendicitis. Exceptionally there 
may be an initial chill. Usually the elevation of temperature is 
moderate, not often exceeding 102° ; in children it may reach 
103.5°. The pulse is accelerated in proportion to the fever. 
Breathing is superficial when the abdominal pain and tender- 
ness are great. 

Nausea and vomiting- may be absent, and when present they 
appear on the second day if the case promises to terminate fa- 
vorably ; in the severe infectious form, vomiting, often with 
hiccoughing, is common. Thirst usually is intense ; the tongue 
is moist and furred, rarely dry. Constipation is the rule, but 
there may be diarrhoea, especially in children. 

Palpation develops great tension in the right rectus muscle 
and tenderness and severe pain in the right ileac fossa (McBur- 
ney's point: about two inches from the anterior superior spine 
of the ileum in a line drawn from it to the navel). A little 
later, a diffuse or clearly defined swelling may be found in the 
right ileac fossa, some two inches, usually, above Poupart's 
ligament. If the tumor is small, or when it lies underneath a 
coil of intestines, it is beyond reach of detection, save as it may 
be found by the finger introduced into the rectum. 

The urine is scanty and albuminous, and there may be con- 
siderable irritability of the bladder ; the position of the patient 
is usually on the back or right side, with the right leg drawn 
up toward the abdomen. 

Course.— Mild cases are likely to recover in a few days, per- 
haps in a week or ten days, with gradual lessening of the pain 
and tenderness to touch and pressure. The occurrence of a 
natural stool is highly indicative of an early and favorable ter- 
mination. Other cases run a somewhat more tedious course, 
with more or less fever, recovering in a few weeks. The re- 
covery, however, may not be complete. A chronic inflammation 
of the appendix may remain ; or there may have been sufficient 
involvement of the peritonaeum to cause circumscribed adhe- 
sion ; or a tumor may be left, probably indicative of pus-forma- 
tion. In either case there are likely to be recurrences of the dis- 
ease. Talamon describes an "appendicular colic," due to the 
partial occlusion of the appendicular lumen, resulting in par- 
oxysms of violent and irregular peristalsis of circular and long- 
itudinal muscles with the expulsion of mucus. 



846 DISEASES OF THE DIGESTIVE ORGANS. 

If there is at the end of the first week no improvement in the 
totality of the constitutional symptoms or in the local affec- 
tion, or if these should be worse, the formation of an abscess 
may be expected. To warrant this, there need not be of neces- 
sity an increase of fever, although such is frequently the case ; 
neither is pus-formation always delayed for this length of 
time ; as a matter of fact, as early as the fourth or fifth day an 
examination may reveal an induration sufficiently large to 
prove the forming of pus. 

Abscesses vary as to size and situation. Those located in the 
pelvic cavity are of particular interest. They may empty 
through the rectum, vagina or bladder, or through some exter- 
nal opening, with the possibility of recovery if well-drained. 
The danger of septicaemia is apparent. Death occurs from 
septicaemia, haemorrhage, or pylephlebitis. 

Perforation into the peritoneal cavity is nearly always fol- 
lowed by fatal diffuse peritonitis. It constitutes the most 
startling complication which may arise at any time after pus 
has formed, even as early as the second or third day. The 
symptoms are: intense pain in the abdomen, excessive abdom- 
inal tenderness, great distension, severe and frequent vomiting, 
hiccoughing, frequent, small, thready, soft pulse, coldness and 
blueness of the surface with, often, a high internal tempera- 
ture, superficial breathing, Hippocratic countenance. 

A general peritonitis may result from extension of the inflam- 
matory process ; in fact, this may be the case at the very begin- 
ning. It is recognized with difficulty. A most careful watch 
upon the general symptoms is absolutely necessary, since they, 
rather than the local condition, indicate the presence of this 
form of peritonitis. It must be remembered that the fever, even 
in such cases, may be moderate after the first three or four days, 
the thermometer registering only from 100° to 100. 5 C F. 

Relapses, it is estimated, occur in twenty -four to forty-five 
per cent, of all the cases. They appear at varying intervals, 
perhaps every few months, then to disappear entirely, or with 
such frequency— brought on, perhaps, by the slightest indiscre- 
tion in diet — as to render the patient a chronic invalid. The 
pathological condition in such cases is that of an obliterated 
inflammation, or of adhesion, or of a small localized circum- 
scribed abscess held within a capsule of dense fibrous tissue. If 



APPENDICITIS. 847 

the chronicity of the case has been well established, an oper- 
ation constitutes the most satisfactory treatment. 

Diagnosis. — The diagnosis depends upon the sudden appear- 
ance of severe localized pain in the right ileac fossa, with fever, 
with or without induration, tenderness to touch and pressure 
at McBurney's point, with constipation, occasionally diar- 
rhoea, and mild gastric disturbances, all these occurring prefer- 
ably in young subjects. 

It is differentiated from strangulation and intussusception 
by the presence of faecal vomiting in the former, coupled with 
the fact that the seat of pain, with rare exceptions, is not in 
the region of the caecum ; intussusception has bloody stools 
and tenesmus. 

Since public attention has been so persistently drawn to ap- 
pendicitis as a disease of great frequency, many cases of imagi- 
nary appendix disease occur, and a physician must be the more 
careful in making the diagnosis. Thoroughness in observing 
and properly estimating the value of symptoms will usually 
prevent serious mistakes. That these are not always exercised 
is proved by the fact that in many instances operations have 
been undertaken when the appendix was found perfectly nor- 
mal. 

Among other affections which simulate appendicitis, but 
which can be differentiated, may be mentioned : pelvic perito- 
nitis and disease of the tubes, acute hsemorrhagic pancreatitis, 
typhoid fever, mucous colitis with enteralgia, perinephritic and 
pericaecal abscess, circumscribed peritonitis in the region of the 
caecum, and even hysteria. 

Prognosis. —Recovery is the rule. Statistics gathered by 
Hawkins, of London (1895), show that 264cases treated at St. 
Thomas's Hospital, representing all forms of the disease, gave 
a mortality of fourteen per cent. Tables compiled by other ob- 
servers make a similar showing. In private practice the results 
have been even much more satisfactory. 

Treatment. — Osier, who practically relegates to the surgeon 
all cases of appendicitis, truthfully remarks that it is the ele- 
ment of uncertainty in individual cases which has sanctioned 
almost exclusively surgical methods in the treatment of this 
affection. Nevertheless, appendicitis belongs to the domain of 
the physician, and should be transferred to the surgeon only in 



848 DISEASES OF THE DIGESTIVE ORGANS. 

exceptional cases. Lives, it is true, have been sacrificed by 
stubborn unwillingness on part of the patient to submit to an 
operation when such a procedure was pointedly indicated, and 
also by neglect on part of the physician to place cases into the 
hands of the surgeon while yet there was a chance to obtain re- 
lief from an operation. Still, "meddlesome" surgery has been 
very busy with this class of sufferers and is responsible for a 
vast amount of mischief done. There is abundant evidence of 
a rebound from the overwhelmingly surgical treatment which 
has been the fashion, and which at no time was based upon 
sound reasoning. 

Surgical interference is justified and necessary to afford exit 
to pus already formed ; in cases of perforation and for the 
treatment of its consequences ; in chronic relapsing cases which 
have resisted other methods of treatment and are threatening 
to destroy or seriously impair the comfort and usefulness of the 
patient. 

The use of opium for the relief of the severe pain of appendi- 
citis is mischievous and inexcusable. So much depends upon 
the early recognition of symptoms indicative of the approach 
of dangerous complications that a knowledge of the character 
and degree of pain is an absolute necessity. Whatever under 
these circumstances blunts the consciousness of the patient 
must be avoided and constitutes reprehensible practice. 

Rest in bed from the very moment the first S3 r mptom declares 
itself is an absolute necessity. The stomach, also, should be 
allowed rest, and such food as the patient absolutely requires 
should be bland and concentrated, net to burden the intestine 
with a large accumulation of faecal matter. The existence of 
constipation may demand the very cautious use of an enema, 
but even this comparatively harmless measure had better be 
dispensed with in all save exceptionally stubborn cases, so as 
to give the bowel also perfect rest. Laxatives should never be 
employed. Local applications to the abdomen are of ques- 
tionable value ; but no strenuous objections exist to the appli- 
cation of heat over the seat of the pain. 

Therapeutics. — The remedies most likely to prove useful are 
those which exercise a controlling influence over the inflamma- 
tory process and thus may prevent the formation of pus ; pus 
once formed, the exhibition of Hepar sulph., Sdlica and others 



APPENDICITIS. 849 

of that class, though theoretically sound, is of slight practical 
value. 

Belladonna in the early stage covers the totality of symp- 
toms better than any other remedy, and may even prove useful 
later on. It has pain in the abdomen, characterized by exces- 
sive sensitiveness to touch, even the trifling weight of the bed- 
covering being unbearable, and many of the minor symptoms. 
—Mercury will probably follow Belladonna if after twenty- 
four or thirty-six hours the condition of the patient has not 
improved. The indications, by Raue, are: "painful, hard, hot 
and red swelling in the ileo-caecal region, painful to the touch ; 
face red, pale and sickly; tongue red and dry or white and 
flabby ; alternation of chilliness and heat ; constipation or fre- 
quent slimy discharges with straining; sweat without relief." 
If the symptoms calling for Mercury are characterized by great 
intensity, Mercurius corrosiyus should be preferred to the 
milder preparation. These two remedies in general adapta- 
bility to appendicitis stand preeminent. — Arsenicum album, 
though successfully prescribed for an almost infinite variety of 
morbid states, has rarely been used here. A study of its patho- 
genesy suggests its probable value, and I have seen prompt ac- 
tion from it in recent cases in which its well-known character- 
istics were present.— Bryonia is suggested by symptoms of per- 
itonitis, as is Veratrum viride.— Dioscorea has been recom- 
mended when the patient is never free from pain, but has de- 
cided paroxysms of aggravation ; the pain is accompanied by 
"stretching." 

The rapid course of the disease requires prompt action, and 
the more delicate symptoms are so generally overshadowed by 
those which are strictly peculiar to the local affection that dif- 
ferentiation resting upon minute shading is difficult. Hence, 
while theoretically almost anyone of many remedies may be in- 
dicated (as: Gelsemium, Aconite, Rhus toxicodendron, 
Plumbum, Phosphorus, Crotalus, Baptisia, Lachesis, 
Nitric acid, Opium and others) in actual practice Belladonna 
and Mercury outweigh them all. 

Special conditions must be met by remedies homoeopathic to 

them. Here belongs the exhibition of Silica, Arsenic, Hepar 

suph. and Sulphur in fistula ; of Phosphorus, Silica, Sulphur 

or Aurum when there is necrosis of bone ; Bryonia, Baptisia, 

54 



850 DISEASES OF THE DIGESTIVE ORGANS. 

Rhus, Lachesis, Arsenic, and others, when there is a typhoid 
state. 



PHLEGMONOUS ENTERITIS. 

A diffuse purulent infiltration of the intestinal walls, with 
tendency to the formation of an abscess in the deep tissues. It 
is usually a secondary process in connection with strangulated 
hernia, intussusception and chronic obstruction. The symp- 
toms are those of peritonitis or, if the affection is limited to the 
rectum, of peri-proctitis. 

PSEUDO-MEMBRANOUS ENTERITIS. 

Pseudo-membranous enteritis (diphtheritic, or croupous, or 
membranous enteritis) is seen in connection with certain infec- 
tious diseases (as pneumonia, p} r aemia, typhoid fever, tubercu- 
losis), toward the termination of various chronic affections (as 
nephritis, cancer, cirrhosis of the liver), occasionally in the en- 
tero-colitis of children, and in poisoning with lead, arsenic and 
mercury. 

The characteristic lesions vary. In some cases a thin, gray- 
ish-yellow exudate, resting on a deeply congested base, occupies 
the top of the folds of the mucosa, involving the mucous layer 
superficially or deeply, as the case may be. The colon and ileum 
are the favorite seat of this form. Or small patches of a gray- 
ish-white pseudo-membrane are found, chiefly in the caecum 
and colon. Or there is inflammation and enlargement of the 
solitary glands, capped with diphtheritic necrosis, with a ten- 
dency to the formation of ulcers. 

The symptoms are not easily recognized and may wholly es- 
cape observation. Pain and diarrhoea may be present; rarely 
diarrhoea of mucus and blood, with tenesmus. 

MUCOUS COEITIS. 

Mucous colitis (membranous enteritis, mucous colic, tubular 
diarrhoea) is a non-febrile disease of the large intestine, charac- 
terized by the periodical discharge of tenacious, adherent mucus 



MUCOUS COLITIS. 851 

(mucin) in the form of glairy, tenacious stool, in irregular 
masses, or as strands or tubular casts of the bowel. 

The cause of the disease is not known. It is not of frequent oc- 
currence, but when seen, it is in connection with some functional 
affection of the nervous system. Statistics show that about 80 
percent, of the cases occur in young women of a nervous, hyster- 
ical disposition, often the subjects of uterine or ovarian irrita- 
tion or of some menstrual disorder; in rare instances young 
children suffer from it ; exceptionally it has been observed in 
men, nearly always neurasthenics. 

Symptoms — The symptoms are those of recurring attacks of 
abdominal pain (enteralgia) and tenderness, with diarrhoea 
and the passage, with some of the stools, of mucus in masses 
of tenacious, dense slime, or firm, opaque membranous matter 
twisted into the semblance of a rope or retaining the shape of 
the intestine, forming a tubular cast of varying length. The 
expulsion of this substance affords relief from the pain. These 
paroxysms recur at intervals of a few weeks to several 
months, although in some cases the affection appears continu- 
ous. During the interval the patient may give some evidence 
of intestinal irritation and will exhibit the symptoms of the 
associated nervous affection. 

The attacks frequently are painful and exhausting ; blood is 
occasionally seen in the stools ; the nervous system may be in 
a state of great excitement or exhaustion. Any unusual strain, 
fatigue or effort may bring on such an attack. 

The duration of an attack is from a few days to two weeks ; 
of the affection, it is indefinite. It has proved intractable, and 
while not directly involving life, is exhausting and discouraging 
to an unusual degree. 

The treatment consists, first, of measures calculated to re- 
move any existing nervous affection or such uterine or other 
disorder of the reproductive system as may cause or aggravate 
the nervous disease ; secondly, to restore the integrity of the 
mucous membrane of the colon ; thirdly, to ward off the indi- 
vidual attack. The habits of life, as to employment and mode 
of living, must be regulated ; the diet must be nutritious and 
non-irritating; the patient must be kept out of doors as much 
as possible ; irregular hours, trashy reading, and whatever may 
stimulate the neurotic proclivities, must be avoided. If within 



852 DISEASES OF THE DIGESTIVE ORGANS. 

reach, a change of residence or a season of travel should be ad- 
vised. Especial pains must be taken to keep the bowels in 
good order, avoiding both constipation and diarrhoea. 

With particular reference to the abdominal affection consult: 
Agaricus, Aloe, Asarum, Belladonna, Borax, Cactus, Cap- 
sicum, China, Colchicum, Colocynthis, Ferrum, Graphites, 
Helleborus, Hydrastis, Lachesis, Nitric acid, Nux vomica, 
Phosphorus, Pulsatilla, Rhus toxicodendron, Sepia. 

Hale reports a cure by Asarum Europ., five drops of the tinct- 
ure four times a day. Another by Euonymin, one half grain 
three times a day ; he highly recommends Hydrastis and its al- 
kaloids, and speaks favorably of Muriate of Ammonia. 

Pepper urges the use of enemata of a quart of water with 
fifteen to twenty-five drops of nitric acid, the latter to be grad- 
ually increased to fifty drops. 



INTESTINAL OBSTRUCTION. 

Intestinal obstruction (ileus, obstipation, entero-stenosis) is 
a condition in which the passage of faecal matter through the 
intestine is blocked by some mechanical obstacle. It may be 
partial or complete and acute or chronic. 

./Etiology. — Strangulation is the most frequent cause. It oc- 
curs in about 35 per cent, of all the cases ; 90 per cent, in the 
small intestine ; 67 per cent, in the right ileac fossa ; 70 per cent, 
in males ; 40 per cent, of all cases observed are between fifteen 
and forty years of age. Loops of intestine may be caught and 
constricted in any of the pouches and diverticula found in the 
abdominal cavity, as in case of a duodeno-jejunal hernia, in 
which a loop is held in the duodeno-jejunal fossa ; or of a dia- 
phragmatic hernia, the abdominal viscera protruding into the 
diaphragm through some congenital defect in the diaphragm or 
through some injury to that structure. A tear or slit in the 
omentum or mesentery may catch and strangulate a coil of in- 
testine. Or a loop of the gut may be firmly held in a position 
favoring strangulation by some membrane or false ligament, 
the result of a peritonitis, adhering to some part of the abdo- 
minal wall. 



INTESTINAL OBSTRUCTION. 853 

Intussusception or Invagination is the cause in twenty-five 
to forty-five per cent of all cases, and is most frequent in chil- 
dren under ten years of age. The process consists of the slip- 
ping of one portion of the intestine into another, as the end of 
the finger of a glove may slip into the lower portion of the fin- 
ger. Thus three layers are formed: an external or receiving 
layer, a middle or returning layer, and an internal or entering 
layer. The invagination forms a descending cylindrical tumor, 
varying in length from a few inches to a foot, or more. It is 
thought to result from sudden and severe peristalsis of a lim- 
ited portion of the intestine, possibly associated with paralysis 
of an adjacent part. The invagination is oftenest ileo-caecal, 
the ileo-caecal valve descending into the colon (in exceptional cases 
the valve may be felt at the anus). Other forms are: the ileal, 
involving the ileum alone ; the colic, involving the large intes- 
tine ; the colico-rectal, involving the colon and rectum. 

It is probable that the presence of growths, like internal 
polypi, indirectly favors the production of invagination, the 
weight of the growth tending to drag upon that portion of 
the gut to which it is attached. Inflammatory adhesions are 
common. Gangrene may occur, with sloughing and ejection of 
the sloughed portion through the intestine. Cases are on 
record in which spontaneous healing of the parts followed this 
process. 

Volvulus (twists and knots) occurs in three to ten per cent, 
of all cases. It is rare in children, but common in males in the 
fourth decade of life (68 per cent, of all cases). Usually, there 
is a long mesentery, allowing a twisting of the gut in its axis. 
Sometimes a regular knot is formed by other portions of the in- 
testine winding themselves about the pedicle of the "twist." 
The weight of the twisted intestine and its contents, with the 
pressure made upon it by the overlying coils, renders spontane- 
ous correction practically impossible. The accident in about 
one-half of all the cases occurs in the sigmoid flexure ; next in 
frequency, in the caecum. 

Strictures. — These in rare cases are congenital. When so, 
their commonest form is seen in the rectum (atresia ani) ; if 
elsewhere, they are the result of fcetal peritonitis, at the sig- 
moid flexure, in the lower part of the ileum, at the ileo-caecal 
opening. These are incompatible with long duration of life. If 



854 DISEASES OF THE DIGESTIVE ORGANS. 

acquired, they are due to cicatrization from syphilitic, dysen- 
teric or tubercular ulceration. They hardly ever result from 
typhoid ulceration. 

Tumors.— These usually are cancerous; should sloughing oc- 
cur, the discharge of the slough affords relief. Benign growths 
in the intestine (papillomata, adenomata, etc.) produce the 
same effect. Tumors in adjacent parts (as uterine tumors or 
ovarian cysts) may compress and obstruct a portion of the in- 
testine. The same effect may be caused by exudates from tuber- 
cular peritonitis ; or compression may result, especially at the 
sigmoid flexure, from a coil filled with faecal matter encroaching 
upon an adjacent coil. 

Abnormal contents of the intestine (obstruction) largely re- 
fers to the presence in the intestinal canal of accumulations of 
faecal matter firmly impacted (coprostasis) and at times at- 
taining a remarkable size. Their growth is gradual, and for a 
long time nature endeavors to overcome the obstruction by 
channelling a passage through the solid mass ; eventually these 
efforts prove in vain and the obstruction becomes complete. 
Obstruction may occur at any time of life. It is seen as the re- 
sult of obstinate constipation in small children, in old people, 
and especially in women, when the rectum is absolutely blocked 
by a solid mass of hard faecal matter which can only be re- 
moved by painfully digging it away with the fingers. Obstruc- 
tion by gall-stones occurs usually late in life, oftenest in the 
ileo-caecal region and in the duodenum. Enteroliths are formed 
by the deposit of phosphates of lime and magnesia around 
some foreign body, as a mass, of hair or some tough fibrous 
substance. They are infrequent. Of late it is thought that per- 
sons who live upon a diet largely composed of oat-meal suffer 
from enteroliths, their center or core consisting of portions of 
oats (avenoliths). Foreign bodies in the intestine, as coins, 
stones of fruit, and other substances occasionally swallowed, 
usually pass through the alimentary canal and rarely give rise 
to obstruction. 

Functional obstruction (idiopathic ileus) is a term applied to 
a rare form of obstruction which depends upon paralysis of 
some portion of the intestine, rendering it unable to peiform 
the peristaltic function. It is associated with disease of the 
brain and cord and with hysteria ; it may be caused by a blow 
upon the abdomen or, in rare cases, follow peritonitis. 



INTESTINAL OBSTRUCTION. 855 

Symptoms. — The symptoms of acute obstruction are pain, 
vomiting, constipation. While at times there are premonitory 
symptoms, such as uneasiness in the bowels and constipation, 
the onset usually is sudden and violent. A sharp pain in the 
bowels abruptly appears as the patient is walking about or is 
busy at some task ; this at first is colicky ; it rapidly increases 
in intensity until it is almost unbearable. Soon it becomes dif- 
fused over a considerable area, but is always particularly se- 
vere at the spot where it was first felt. Vomiting follows very 
soon, and is constant and distressing; it is first gastric, then 
becomes bilious, then stercoraceous, of brownish-black color 
and pronounced faecal odor. The ejected substance does not 
consist of faecal matter proper, ejected by reverse peristaltic 
action, but of the rotten, decomposed contents of the intesti- 
nal pouch formed above the seat of the obstruction. In cases 
approaching a fatal termination the vomiting may suddenly 
cease, being replaced by constant and distressing hiccough. 
Constipation is absolute after the bowel below the seat of ob- 
struction has become emptied; there is even cessation of the 
emission of flatus. Rapid distension of the abdomen, chiefly 
above the seat of obstruction, takes place ; hence the distension 
is comparatively slight when the obstruction is in the smaller 
bowel, and immense when in the large intestine. Efforts on 
part of the intestine to overcome the obstacle result in violent 
peristalsis above the seat of obstruction, with rumbling of 
gases and borborygmi which are easily heard in the room. Ten- 
derness throughout the abdomen soon develops, and after a 
little becomes excessive. 

The constitutional symptoms are severe from the beginning, 
and grow worse rapidly. There is much restlessness and anx- 
iety from the start ; the features assume quickly a drawn, hag- 
gard, anxious expression ; the eyes are sunken ; the face pinched; 
the tip of the nose cold; the surface of the body bathed in cold, 
clammy sweat. The tongue is dry and parched; the voice 
husky, the pulse rapid and thready, and respiration shallow ; 
urine is scanty, high-colored and even suppressed. The temper- 
ature at first may be moderately elevated, later it becomes nor- 
mal, then subnormal. These symptoms, indicative of collapse, 
deepen, and death from shock, sometimes preceded by coma, 
occurs in from two to six days. 



856 DISEASES OF THE DIGESTIVE ORGANS. 

Chronic obstruction is almost always the result of gradually 
increasing faecal accumulation at some point, and is preceded 
by symptoms indicating intestinal constriction. There is a 
tendency to constipation, the bowels moving at irregular and 
long intervals, with much effort and considerable pain. The 
stools may attract attention by their peculiar shape, which, 
however, is not seen in this condition only. In some cases the 
stool is long, slender, ribbon-shaped ; in others, furrowed on one 
side; again, it appears in small, round balls, like the excrement 
of sheep. If the seat of constriction is in the small intestine, 
the contents of which are semi-fluid, constipation may not 
exist and the passages may even be diarrhoeic. Distension of 
the abdomen is common, but comparatively moderate when 
the constriction is in the small bowel. Peristaltic efforts are 
pronounced. They are plainly visible, and often the outlines of 
the involved intestine may be distinctly and easily traced or 
felt, thus aiding greatly in fixing the seat of the trouble. 

Unless relieved, the condition gradually, in the course of 
weeks, months or even years, develops until we suddenly deal 
with an unmistakable case of obstruction. It may be assumed 
that the constipation has become more and more troublesome, 
although the obstructing mass has been channelled and there has 
been an escape of semi-fluid stool from the small intestine; 
sometimes even a mucous diarrhoea has been noted. Suddenly, 
however, vomiting sets in, with severe abdominal pain and 
other threatening symptoms, or an intense colitis or peritonitis 
may result from the presence of the hard, immovable mass of 
faecal matter, undoubtedly favored by the rapid growth of 
germs which thrive in the abdominal contents of the intestine 
above the stricture. In some cases absolute retention of faeces 
may exist for a long time, even weeks, without causing serious 
disturbance. In the development of this condition the walls of 
the intestine at the seat of a severe stricture may become 
thinned, and are thus easily perforated ; or diphtheritic inflam- 
mation may set in, with a tendency to ulceration. The wall 
above the seat of the stricture usually assumes a condition of 
hypertrophy from the prolonged effort of the muscular struct- 
ure to overcome the obstacle. Below the constriction the gut 
is empty and contracted. 

The constitutional symptoms of chronic obstruction are 



INTESTINAL OBSTRUCTION. 857 

those of general progressive impairment of health, emaciation, 
loss of strength, anaemia and, upon the culmination of the ob- 
struction, death with symptoms as described. 

Diagnosis. — The diagnosis deals not only with a differentia- 
tion of this affection from other and similar diseases, but aims 
to determine the location of the obstruction and its character. 

In attempting to determine the location and character of an 
obstruction, examination should be made by the rectum and 
vagina, with palpation and inspection of the abdomen. Ex- 
amination per rectum reveals invagination of the bowels and 
the presence of a faecal mass in the rectum. Vaginal examina- 
tion demonstrates the presence of such lesions of the pelvic or- 
gans as by encroaching upon the intestine may have produced 
the obstruction (as uterine and ovarian tumors, etc.). Not in- 
frequently the collapsed, flaccid gut below the seat of the ob- 
struction falls into the pelvis and may there be recognized. 
Palpation will fix the seat of special tenderness, or detect a tu- 
mor or an old strangulated hernia. Inspection will show the 
spasmodically contracting or distended coil of intestine above 
the seat of stricture. Thus much may be learned. Wyllie 
points out that in obstruction of the lower portion of the large 
bowel the colon may stand out plainly in horse-shoe pattern, 
while in obstruction of the caecum or lower end of the ileum 
the so-called ladder-pattern is produced by violent visible peris- 
talsis of the small intestine. The shape of the abdomen also is 
of diagnostic value. 

The following aid in locating the point of obstruction. If the 
duodenum or jejunum : abdominal distension is slight, vomit- 
ing and collapse occur early, and there probably is suppression 
of urine. If the ileum and caecum: the distension is most pro- 
nounced in the umbilical region ; this, being rounded and raised, 
gives to the flanks a flattened appearance. The course is rapid, 
with early faecal vomiting. If the colon or rectum: general 
and uniform distension of the abdomen. The symptoms are 
less intense ; the urine is less scanty than when the obstruction 
is in the upper bowel, and there may be tenesmus. — Distension 
of the lower bowel by the injection of water has been practiced 
for diagnostic purposes, but is not conclusive. If the bowel 
holds less than four quarts of water, an obstruction in the up- 
per portion of the large intestine may be suspected. The injec- 



858 DISEASES OF THE DIGESTIVE ORGANS. 

tion must be made with care and under low pressure, with a 
fountain syringe moderately elevated, not over six feet high in 
children nor more than fifteen feet in adults. The patient 
should be anaesthetized and placed in the dorsal position, with 
the hips raised. 

Strangulation occurs suddenly, usually after an exertion, 
and is accompanied with excessive pain and early vomiting, 
which is copious and soon becomes stercoraceous. There is 
early and great prostration ; late distension and tenderness ; 
constipation is absolute. Tumor can be detected in only excep- 
tional cases. Rectal examination reveals nothing. History of 
injury to the abdomen or of preceding peritonitis. Intussus- 
ception, almost always in children. Onset sudden. Prostra- 
tion early and profound. Vomiting early, but rarely faecal. 
Little, if any, abdominal distension. The abdomen may be flat. 
In fifty per cent, of all the cases the tumor may be detected per 
rectum. Tumor in right ileac fossa, seen early. Tenderness 
about the tumor. Tenesmus and passing of blood-stained mu- 
cus, early, in about fiftj'-five per cent, of all the cases. Fascal 
obstruction : course one of gradual development. Historj* of 
chronic constipation, with sudden onset of S3'mptoms of acute 
obstruction. Mass can often be felt. Pain, nausea and vomit- 
ing late. In very exceptional cases diarrhceic discharges from 
the catarrhal irritation of the intestinal mucous membrane. 
Obstruction by foreign bodies: almost always has a history of 
some foreign substance having been swallowed, with pain and 
discomfort arising from it, culminating in acute symptoms of 
obstruction when lodged. There will then be increasing pain, 
with rapidly developing abdominal distension and tenderness, 
vomiting not setting in until late. If due to an impaction of 
gall-stones, the history of the case (gall-stone colic) will aid the 
diagnosis. When impacted in the duodenum, the symptoms 
are violent from the beginning, with persistent bilious vomit- 
ing, suppression of urine and rapid progression of the case to 
collapse. 

The symptoms are so well-marked that a differentiation from 
other affections is not often difficult, with the exception of 
acute hemorrhagic pancreatitis and acute enteritis. The 
former may easily be mistaken for obstruction, and expert di- 
agnosticians have failed to distinguish between the two. When 



INTESTINAL OBSTRUCTION. 859 

the onset of acute enteritis is sudden, the vomiting intense, and 
distension of the abdomen and tenderness occur rapidly, the re- 
semblance to obstruction is striking, but the character of the 
vomitus and the physical signs will establish the diagnosis. Ap- 
pendicitis has a more continuously elevated temperature and 
there may be a history of previous attacks of the same charac- 
ter. 

Course and Termination. — Acute obstruction usually termi- 
nates fatally in from two to six days. Chronic cases may con- 
tinue for an indefinite length of time, with the constant danger 
of acute symptoms setting in at any time. The prognosis is 
rather unfavorable in all cases, least so from obstruction which 
results from the impaction of faecal matter ; in these relief is 
sometimes had by the sudden expulsion of the offending sub- 
stance. But even in other cases recovery may take place under 
seemingly hopeless conditions, such as occurs when a large 
strangulated mass has sloughed off and is passed through the 
intestine. 

Treatment —It is evident that throughout pains must be 
taken to maintain the strength of the patient in every way 
possible. Easily assimilated food of a character that yields 
very little residue must be given at stated hours ; stimulants, 
as iced champagne or whisky, may be administered, and pieces 
of ice sucked to relieve thirst and vomiting. 

Mild laxatives, as castor oil, may be cautiously used, but 
purgatives are dangerous and not to be considered. The appli- 
cation of cloths wrung out of hot water is grateful to the pa- 
tient and may prove useful. Kuessmaul, Cohn, and others, 
recommend lavage of the stomach, claiming that it not only re- 
lieves the vomiting, but often, by removal of decomposing mat- 
ter, lessens the distension and pressure, and thus proves of 
great service ; it stimulates peristalsis. Irrigation of the large 
bowel with a siphon syringe has warm advocates. Jonathan 
Hutchinson advises that the patient be anaesthetized, the abdo- 
men thoroughly kneaded, and a copious enema given while 
in the inverted position. "Then, with the aid of three or four 
strong men, the patient is to be thoroughly shaken, first with 
the abdomen held downward, and subsequently in the inverted 
position." 

Inflation by forcing air into the rectum has been practiced. 



860 DISEASES OF THE DIGESTIVE ORGANS. 

The operation is done with a bellows or proper syringe, but 
care must be exercised not to rupture the bowel. Fitz states 
that out of forty -four cases treated by irrigation and inflation 
thirty-three recovered and eleven died. 

Tympanitis requires hot applications to the abdomen or the 
turpentine stupe. If excessive, relief may be afforded by punc- 
turing the bowel with a fine aspirator needle; there is, how- 
ever, some danger of the escape of faecal matter, followed by 
peritonitis. 

If improvement does not occur on the third day, surgical in- 
terference, including laparotomy, becomes advisable, even im- 
perative. The safety, now, of operations which until a few 
years ago were full of risk vastly increases the responsibility of 
the physician in these cases. 

The management of the chronic form, or of constriction, is 
centered upon intelligent medication and regulation of the pa- 
tient's diet, insuring generous nutrition and the smallest possi- 
ble residue. 

Reference has been made to the removal of impacted masses 
of faeces from the rectum; it is accomplished by the use of some 
blunt instrument, as a spoon, or b}- the fingers, aided by re- 
peated injections of warm water with soap, olive oil, or some 
other softening substance (see "Constipation"). An infusion 
of tobacco, thrown into the rectum, is a favorite remedy with 
the common people in Europe when the services of a physician 
cannot be had, and is known to have rendered very good ser- 
vice. 

Therapeutics. — It seems scarcely rational to exhibit a 
remedy for the purpose of meeting dangerous symptoms which 
depend wholly upon the presence of mechanical causes ; but 
there is nothing irrational in exhibiting remedies which may 
aid in keeping these symptoms under control while other 
efforts are made to remove the mechanical cause. The very 
gravity of the case warrants our doing all that can be done 
for the patient, and there certainly is less probability of our 
doing harm by the exhibition of a well-chosen simple remedy 
than by the use of purgatives, heavy doses of opium, or the 
once so fashionable, and even now frequently advocated, em- 
ployment of heavy masses of metallic quicksilver. Common 
sense, however, suggests that the exhibition of a remedy is 



CONSTIPATION. 861 

only one of many things to be done and that it would be 
criminal folly to depend upon it alone. 
The remedies most likely to be of service are: Belladonna, 

COLOCYNTHIS, NUX VOMICA, OPIUM, PLUMBUM, VERATRUM AL- 
BUM, Arsenic, Cuprum. 



CONSTIPATION. 

Constipation, retention of stool, or difficult or tardy expul- 
sion of stool, is often the result of an inherited tendency which 
is strongly pronounced in some families ; it is more frequent in 
women than in men and in brunettes than in persons of light 
complexion. Diet is frequently at fault, food being habitually 
used which affords too little or too much residue. Sedentary 
habits, especially when coupled with a hearty appetite and an 
occupation which closely absorbs the attention of the patient 
and thus leads to neglect of the calls of nature, almost surely 
leads to stubborn constipation. Often it is the result of 
atony, of a loss of energy in the peristaltic movements of the 
intestine, which may be due to general weakness of the body or 
to some affection of the intestine itself. Acute and chronic en- 
teritis are commonly accompanied by constipation; & jaundiced 
state produces the same result, presumably from that absence 
of excitation in the intestine which the presence of bile is 
thought to cause. Affections of the brain and cord may inter- 
fere with normal inhibition, thus deranging the delicate ma- 
chinery upon the perfect working of which the act of digestion 
and the onward propulsion of stool depends ; many of the psy- 
choses, as hypochondriasis, are almost invariably associated 
with constipation. In certain acute fevers this state is com- 
mon. One of its most fruitful causes is the habit of constant 
drug-taking, especially the habitual use of cathartics. 

Among other causes may be mentioned : Weakness of the ab- 
dominal muscles from obesity or, in women, from the strain 
put upon them by many pregnancies. Intestinal strictures or 
tumors (large scybala), or atony and dilatation of the colon, 
especially at the sigmoid flexure, with dilatation of the sacculi. 
Contracted state of the bowel, resulting from dysentery or ul- 



862 DISEASES OF THE DIGESTIVE ORGANS. 

cerative colitis or in hysterical women who suffer from uterine 
disease. Gastric disorders also cause constipation, probably 
from reflex action. 

The constipation of infants usually depends upon general 
muscular atony, torpor of the liver and intestinal glands, im- 
proper feeding (including poor quality of breast-milk and the 
excessive use of starchy foods), and too ready recourse to cas- 
tor oil, fig-syrup, and other popular laxatives. Constipation 
of the aged arises from inabilitj^ to property masticate food, ab- 
sence of regular and needed physical exercise, and general 
atony. 

Symptoms. — Constipation, especially when habitual, may 
persist indefinitely without giving rise to serious consequences 
or even inconvenience. In the majority of cases unusual tor- 
pidity of the bowels tends to heavy, dull headache, loss of ap- 
petite, furred tongue, bad taste in the mouth, lassitude, and 
sense of slight malaise. Mental uneasiness and despondency re- 
sult more often from the very common, and in the main cor- 
rect, belief that daily evacuations are necessary to the mainte- 
nance of health, and from worry, especially in nervous people, 
because of temporary failure to accomplish the desired end. 

Indirectly, a large and varied list of troubles is the legitimate 
outcome of constipation of long standing. Thus in women the 
presence of hard masses of faecal matter in the bowel tends to 
greatly aggravate menstrual pain and may become a cause of 
uterine disease ; neuralgia of the sacral nerves often arises from 
pressure of stool in the sigmoid flexure ; haemorrhoids and ul- 
ceration, especially in the colon, and enteritis are legitimate re- 
sults of long-continued retention of stool. Even more serious 
consequences may result, such as intestinal obstruction. Ac- 
cumulations of hardened faecal matter may frequently be felt 
in the colon, especially at the hepatic and splenic flexure, form- 
ing an irregular lumpy tumor or sausage -like masses. 

Treatment.— It is of first importance to determine, if poss- 
ible, the primary cause and to regulate the life and daily habits 
of the patient. A reasonable amount of exercise, especially on 
part of those whose habits are sedentary, is in itself capable of 
accomplishing much good. It is equally necessary to insist 
upon prompt compliance with the calls of nature. Wrong no- 
tions of propriety must not be allowed to stand in the way. 



CONSTIPATION. 863 

When the habit has become confirmed, the patient must be 
made to visit the bath-room or closet at a stated hour, prefer- 
ably soon after breakfast, there to remain long enough to al- 
low an evacuation to take place, but without doing unneces- 
sary "straining," -which does more harm than good. Even 
though no immediate results may be obtained, in the majority 
of cases the bowels will after a time begin to move, and regu- 
larity may thus be insured. Women and children are much 
given to not allow nature sufficient time when they visit the 
closet, and this pernicious habit of "hurrying" must be broken. 
I know of a mother who had become wise through personal 
suffering, who did not permit her children to leave the seat of 
the closet in less than fifteen minutes in the morning, and who 
thus effectively overcame the natural tendency to constipation 
which had been inherited . 

Much assistance can be had from the regular observance of 
certain rules which universal experience has proved to be bene- 
ficial, such as taking a glass of cold -water upon rising, before 
breakfast, or a drink of hot -water before retiring. 

A proper diet is indispensable to a cure. Persons who eat 
too much meat, egg or fish must be made to add vegetables, 
coarse brown breads and fruits to their dietary ; the reverse 
must be urged in appropriate cases. Often it is necessary to 
insist upon the necessity of taking liquids more freely, for some 
persons drink too little. It is exceedingly difficult to point out 
just what changes must be made, for the necessities or prefer- 
ences of any two people are rarely the same ; but in a general 
way it is safe to demand the use of a judiciously mixed diet, 
with brown bread (corn, whole wheat, rye) in preference to 
white bread ; oat-meal mush for breakfast ; fresh vegetables 
(salads, spinach, onions, especially boiled) and a generous 
amount of pure water or of aerated mineral water. 

When these are not sufficient, massage will often be found 
very helpful. For home-treatment, a metal ball, weighing from 
four to six pounds, rolled each morning to and fro upon the 
abdomen for ten or fifteen minutes, answers the purpose; the 
manipulations of an experienced operator are, of course, pref- 
erable. Electricity is of undoubted value in very many cases. 
Rockwell (International System of Electro- Therapeutics) says : 
"In a certain proportion of these cases electricity is of positive 



864 DISEASES OF THE DIGESTIVE ORGANS. 

value, accomplishing more perhaps than most other methods 
of treatment. Both the galvanic and faradic currents may be 
used, but my preference has been and is for the faradic. Its 
powerful mechanical and limited reflex effects seem to be better 
adapted to restore the impaired irritability of the muscular 
coats. In the intestinal paralysis due to distension from re- 
tained faeces and from the action of powerful cathartics, the 
best results are obtained from internal applications, sometimes 
by the unipolar, sometimes by the bipolar, method. In the 
unipolar method, one pole, preferably the anode, is introduced 
into the rectum, while the other is applied externally to every 
part of the abdomen as well as to the dorsal and lumbar re- 
gions of the back. If the galvanic current is employed, the 
cathode should invariably be placed internally, the extent of 
the introduction depending upon the necessities of each indi- 
vidual case. The strength of the galvanic current should 
hardly exceed two or three milliamperes even when used with 
constant interruptions, but when used continuously without 
interruptions one, or at most two, milliamperes are amply suf- 
ficient. The strength of the faradic current may be safely left 
to the sensations of the patient. Whatever can be borne with- 
out great discomfort is safe to use. To those who understand 
the exceedingly powerful influence of an induction current of 
quantity, when applied to surfaces that offer little resistance 
to its passage, it is at once evident that it is to be greatly pre- 
ferred to currents of tension in exciting intestinal muscular con- 
traction. In order that the resistance may be reduced to its 
minimum, both poles should be introduced into the bowel, 
using for this purpose a bipolar electrode. Induction currents 
of high tension, when applied to mucous surfaces, act mildly 
both on motor and sensory nerves. Indeed, so tolerant do 
these parts soon become to such a current that, even when the 
strength is very great, the patient may be entirely unconscious 
of its passage. The induction current of quantity, on the con- 
trary, requires the exercise of the greatest caution. Excessive 
pain is occasioned by strong applications, and the parts do not 
become tolerant to its influence as the application continues. 
Impaired peristaltic action dependent upon constitutional con- 
ditions, the result of either acute or chronic diseases, demands 
more than local treatment. In addition to this local treat- 



CONSTIPATION. 865 

ment with the induction currents of quantity and by the bipo- 
lar methods, or more often entirely superseding it, the treat- 
ment by general faradization is beyond all question productive, 
in many instances, of the most beneficial results. For this pur- 
pose currents of comparatively high tension are required, and 
when thoroughly and judiciously applied, the method is suffi- 
cient to increase the processes of waste and repair, improving 
nutrition and imparting tone to the system generally and 
locally. The internal electrode should invariably be attached 
to the negative pole of the battery." 

In case of lax, pendulous abdomen, a firmly applied abdomi- 
nal bandage may prove helpful ; its support affords increased 
energy in expulsive power of the abdominal muscles. 

If immediate relief seems necessary, an enema of warm water, 
with milk, castile soap, or a small amount of lard added, is un- 
objectionable. It must be taken with the patient in the re- 
cumbent position and by means of a fountain syringe, the in- 
jection to be retained as long as possible. Glycerine supposi- 
tories are very efficient. Laxatives and cathartics are to be 
scrupulously avoided ; they, no doubt, have done more toward 
firmly establishing habitual constipation than all other foolish 
habits combined. When their occasional use is absolutely un- 
avoidable, bitter waters, as Hunyadi or Friedrichshalle, are to 
be preferred, or an aromatic syrup of cascara sagrada may be 
given. If impaction of faeces exists, a large injection of olive 
oil, from fifteen to twenty ounces, slowly administered, is ex- 
cellent ; it may have to be repeated, and should, in fact, be con- 
tinued daily, in smaller amounts, until the removal of the entire 
mass has been accomplished. 

The constipation of children must be treated as that of 
adults, with particular attention to diet and, if old enough, to 
immediate and patient obedience to the calls of nature. Infants 
demand very careful attention to diet. If breast-fed, they are 
often benefited by having given them two or three teaspoonfuls 
of cream before being put to the breast. If bottle-fed, Mellin's 
food is preferable, usually, to a pure milk -diet. Drinks of water 
should be frequently given ; children are fond of water, and 
often receive a supply quite insufficient to maintain that soft- 
ness and moisture of the stool which is a physiological neces- 
sity. Enemata, in case of small children, need not be large, a 
55 



866 DISEASES OF THE DIGESTIVE ORGANS. 

few ounces being quite sufficient; glycerine in proportion of one 
part to three parts of water may be added when necessary. 
Suppositories of soap or glycerine excite a prompt evacuation, 
but should only be allowed when in a case of habitual consti- 
pation the child has been permitted to go too long without a 
stool. 

Therapeutics. — The well-selected remedy is capable of yielding 
excellent results in the treatment of the constipation of both 
adults and infants. The following are especially reliable: Nux 
vomica. Frequent but ineffectual desire for stool ; stools large 
and hard ; colic ; indigestion ; dull heavy headache, especially in 
the morning; indigestion; general indisposition ("out of 
sorts"); irritability and despondency. In persons of sedentary 
occupation, fond of stimulants, in the habit of using irritating 
drugs. Constipation alternating with diarrhoea. "Bilious" 
condition. — Bryonia. Stools large, dry and hard, as though 
burnt; passed with great difficulty. Indigestion, with heavi- 
ness and pressive pain in the stomach, especially after eating; 
bitter taste in the mouth ; thickly coated, whitish-yellow 
tongue. Irritability of temper. — Opium. Constipation from 
intestinal inertia, especially of the rectum. Has no inclination 
to stool. Stools hard, dark-brown, in small, hard balls. Severe 
flatulent colic in upper bowel. — Plumbum. Characteristic vio- 
lent colic, with tense, drawn-in abdomen; jaundice; stools 
small, hard, like sheep-dung; constant urging to stool, with 
pressure. Constipation with irritability and constrictive 
spasm of the anus, "especially with the sensation of a string 
pulling the anus into the rectum" (T. F. Allen). In infants, 
stools hard and crumbled.— Lycopodpum. Chronic persistent 
constipation, with hard stool and spasmodic and painful con- 
striction at the anus, the stool being followed by pain and sore- 
ness in the rectum and anus. Gurgling and rumbling in the ab- 
domen from flatulency. Chronic disease of the liver. Chronic 
gastric catarrh, with great gastric flatulency; acid, chronic, 
atonic dyspepsia, mental depression, copiously bleeding haemor- 
rhoids.— Alumina. Particularly useful in children. Stools very 
hard ; rectum inactive, dry, inflamed. Bleeding after the painful 
expulsion of large, dry hard stool. Stool soft, like putty, ex- 
pelled only after much effort; the rectal and abdominal muscles 
combined are unequal to the task. — Graphites. The stools 



ENTERALGIA. 867 

are large and covered with mucus. Distension from flat- 
ulency of moderate severity. Indigestion, with pain in the 
stomach some hours after eating. Itching, moist eczema, espe- 
cially behind the ears. Haemorrhoids.— Sulphur. Habitual 
constipation with irritability and dryness of the rectum and 
soreness and burning at the anus ; frequent, ineffectual desire 
for stool; haemorrhoids ; liver-trouble; rush of blood to the 
head ; cold feet. After stool the anus is so sore that he cannot 
lie down or sit down ; prolapsus ani. 

Haemorrhoidal affections being frequently associated with 
constipation, their presence may further suggest: ^Esculus 
hippocastanum. Piles purple ; protrude ; bleed slightly ; ful- 
ness and bearing-down ; sensation as of sticks in the rectum ; 
aching pain and lameness in the back; dry, hard stool. — Aloes. 
Piles protrude like a bunch of grapes, with constant bearing- 
down in the rectum ; stools mucous, jelly-like ; haemorrhoids 
swollen and sore, can hardly use the toilet paper; soreness re- 
lieved from the use of cold water.— Belladonna. Profuse 
arterial bleeding from the piles ; congestion ; sensitiveness and 
soreness, so he must lie with the nates spread apart. — Lachesis. 
Stitching pain upwards in the pile-tumor, when coughing. 
Beating in the anus as from little hammers. Haemorrhage of 
dark blood, which does not coagulate easily. — Nitric acid. 
Painful, pendulous haemorrhoids that have ceased to bleed. 
Ulceration of the rectum, with severe pains after stool. Fis- 
sure of the anus, with oozing of fetid moisture and intense raw- 
ness and smarting. 



ENTERALGIA. 

Enteralgia, enterodynia, intestinal colic, may be considered in 
the light of a neuralgia of the intestine. 

/Etiology. — The predisposing causes are such as play an im- 
portant role in the causation of a neuralgia in any other por- 
tion of the body. They are: inherited predisposition, neurotic 
temperament, and such conditions as lower and vitiate the 
general tone of the system. Among the latter, worrying and 
fretting, overwork, living amid unheal thful surroundings, im- 



868 DISEASES OF THE DIGESTIVE ORGANS. 

proper food and clothing, and debilitating, exhausting diseases 
are conspicuous. 

Immediate, exciting causes are : local irritation of the termi- 
nal intestinal nerve filaments by the presence of some irritating 
substance (hard fasces, enteroliths, gall-stones, worms, etc.), 
of some foreign body in the canal, or of the presence of some in- 
digestible, spoiled article of food or of substances undergoing 
fermentation (unripe fruit, sour milk, etc.). Some persons 
suffer easily from substances which to others are perfectly 
harmless (strawberries, shell-fish, veal, lemonade, etc.), an idio- 
syncras} r which is well known. Enteralgia may be reflex, as 
in diseases of the uterus, ovaries, liver, kidney, spleen, pan- 
creas ; it may occur in connection with certain diseases capa- 
ble of profoundly affecting and depressing the entire organism 
(as anaemia, malaria), in nervous affections (crises of locomo- 
tor ataxia, hysteria, hypochondriasis), and as the effect of the 
constitutional action of certain poisons, as lead, arsenic, and 
copper. 

Symptoms. — Pain in the bowels is the one symptom which 
overshadows all else. It may begin lightly, gradually increas- 
ing in severity until it is almost unbearable, or its onset may 
be sudden and the violence of the pain very great from the 
start. The pain is usually at or near the umbilicus, radiating 
throughout the abdomen, more rarely of a "shifting" charac- 
ter. It is cutting, pinching, stabbing, tearing and agonizing 
in all but exceptional cases, in which it may be dull and grum- 
bling. Occasionally it is almost continuous, but in the greater 
number of attacks paroxysms of intense aggravation are felt, 
gradually increasing, and followed by periods of comparative, 
but rarely complete, rest. In many cases some relief is felt 
from pressure, and often the patient bends over a chair or some 
other convenient hard article to get the benefit of hard, firm 
pressure. Sometimes, however, great abdominal tenderness ex- 
ists. The skin of the abdomen is tense, and its walls hard and 
drawn-in ; occasionally there is abdominal distension. Excited 
peristaltic action shows itself in the powerful contractions of 
the intestinal coils, which can be seen upon inspection ; these 
are commonly accompanied with violent bearing-down sensa- 
tions. Restless tossing about, loud moans and cries, with a 
drawn, anxious, haggard face and cold bodily surface bear 



ENTERALGIA. 869 

witness to the agony which is endured. Nausea and vomiting 
often exist ; constipation is the rule, with occasional urging to 
stool and vain endeavors to bring about an evacuation; at 
times there is looseness of the bowels. The pulse is almost al- 
ways slow and hard, and there is neither fever nor thirst. 

If the patient is of an exceedingly nervous temperament, va- 
rious reflex symptoms may occur, such as distressing palpita- 
tion of the heart, dyspnoea, hiccoughing, dizziness, faintness, 
cramps and, particularly in children, general convulsions. 

The attacks last from a few minutes to several hours, and 
usually leave the patient as abruptly as they came. They 
recur at varying intervals. 

Diagnosis. — The diagnosis rarely presents any difficultj^. At 
first glance some inflammatory affection of the intestine might 
be suspected, but the absence of fever, including thirst and 
bodily heat, and the relief from hard pressure, with the intense 
character of the pain and the abandon with which the patient 
tumbles about, are alone quite sufficient to do away with this 
impression. Rheumatism of the abdominal muscles lacks the 
relief from pressure and the spasmodic character of the pain ; 
the rheumatic pain is also more superficial and worse from 
motion, and there is the probability of rheumatic manifesta- 
tions in other parts of the body. Intestinal obstruction is dif- 
ferentiated by the localized and continuous character of the 
pain, the absolute constipation, and its peculiar (stercoraceous) 
vomiting. 

The prognosis is good so far as it concerns recovery from the 
individual attack, fatal cases being of very rare occurrence. 
Frequent recurrences may take place at short intervals and ex- 
haust the strength of the patient, thus becoming a factor of 
some importance in the fate of those already suffering from 
some other constitutional affection. Whether, or not, a radi- 
cal cure can be accomplished depends largely upon our ability 
to reach the primary disease. 

Treatment. — The treatment of the individual attack must be 
directed to the removal of the exciting cause, and when this lies 
in the presence of some irritating substance in the intestine it 
can usually be brought about by the use of a smart cathartic 
or a copious enema of hot water. The relief of pain is equally 
important, and to this end hot applications to the abdomen — 



870 DISEASES OF THE DIGESTIVE ORGANS. 

either in the form of poultices or cloths wrung out of hot water 
— or turpentine stupes, should be made constantly, as hot as 
the patient can endure, and changed at brief intervals. A hot 
mustard foot bath is serviceable in milder cases. If the suffer- 
ing is intense, it is perfectly proper to use Hoffman's anodyne, 
spirits of ammonia, chloroform or subcutaneous injections of 
morphia. 

The permanent cure of the patient, in addition to such meas- 
ures as are directed against the primary disease, consists of 
everything tending to build up his strength and to increase his 
vitality and powers of resistance. Whatever accomplishes this, 
is good and appropriate treatment. 

Therapeutics.— Arsenicum. Attack comes on suddenly. Per- 
iodical, burning, cutting pain, with great anguish ; relieved by 
the application of heat ; when a paroxysm is over, he is utterly 
exhausted. Vomiting with pain in the stomach. He is sure 
that he is about to die. Chronic malarial poisoning. The 
symptoms are so severe that fears of some inflammatory con- 
dition seem justified. — Asa fcetida. An excellent remedy for 
hysterical women, when the flatulence is excessive, the abdo- 
men greats distended, and the peristaltic action of the intes- 
tines much excited ; trembling and faintness of the heart, or 
violent, irregular palpitation, with dY-spncea ; spasmodic jerk- 
ing and twitching. The hysterical element is pronounced. — 
Belladonna. Spasmodic, clawing, pinching pain, with exces- 
sive distension of the abdomen, or sausage-like protrusion of 
coils of intestine, and much gurgling in the bowels. Extreme 
sensitiveness of the abdomen to touch, yet moderate pressure 
often relieves ; head feels full and aches ; face red and congested. 
— Colocynthis. Intense, constrictive, pinching, colicky pain 
about the navel, extending in evety direction and hardly endur- 
able ; aggravation from motion, relief from hard pressure, from 
the escape of flatus, and from drinking hot coffee. "Tight, 
cramp-like pain in the left ileac and umbilical region, which is 
worse after (not during) external pressure, especially observed 
in women after excess in venere" (Raue). — Cuprum. Intense 
colic, cutting as though a knife were being drawn through the 
intestines and into the back, extorting violent screams; patient 
perfectly frantic with pain ; cramps in the abdominal muscles, 
sometimes extending into the muscles of the extremities. Con- 



ENTERALGIA. 871 

vulsive vomiting ; hiccoughing ; collapse.— Dioscorea. Intense 
cutting, twisting colic, better from pressure, radiating from the 
abdomen into the back, chest and arms. Severe pain in the left 
ileac region, running upward, toward the left kidney, better 
from bending forward, from crouching forward, with the hands 
clasping the knees. Griping and distress in the umbilical and 
hypogastric regions ; with intermittent cutting in the stomach 
and small intestines. — Nux vomica. Colic from indigestion, 
with pressure upward, causing shortness of breath, and down- 
ward, causing desire for stool, with general soreness, constipa- 
tion, and desire for stool plainly felt all through the bowels. — 
Opium. Obstinate constipation, with flatulent distension of 
the small intestine, giving rise to an urgent desire for stool, 
which increases the cutting, pressive, twisting pain.— Plati- 
num. In hysterical women, subject to irregular and painful 
menstruation and sexual melancholia (the latter in both sexes). 
Constrictive colic; pain extending from the umbilicus to the 
back. Obstinate constipation; frequent desire for stool; feel- 
ing as though the rectum were overburdened with stool, but the 
evacuation is small and painful. — Plumbum. General anaemia; 
intense tearing colic, almost impossible to endure, about the 
navel ; umbilicus drawn in toward the spine ; the abdomen is 
tense and hard ; extreme distension of the transverse colon ; 
tympanitic distension of the abdomen, with circumscribed 
swellings as large as the fist. Stubborn constipation. — Vera- 
trum album. The entire stomach much swollen and sensitive. 
"It is adapted to the most terrible attacks of colic; the pain 
begins in the stomach, radiates upward toward the shoulder, 
and then involves the "whole abdomen, associated with retch- 
ing, vomiting, purging, coldness, cold sweat" (T. F. Allen). 
There is often a great deal of flatulence, with a feeling as though 
the intestines were twisted into a knot, with intense colic ; it 
seems as though the intestinal canal were absolutely closed, so 
he cannot pass the least flatus. 

Enteralgia in children: Pulsatilla, Colocynthis, Rheum 
(everything smells sour about the child ), Stannum (better from 
resting the abdomen upon the point of the shoulder), Ipecacu- 
anha, Cuprum. 

From indigestion : Pulsatilla (fat, pastry), Nux vom. (over- 
eating, coffee), Arsenic (iced water; ice-cream), Ipecacuanha 
(unripe fruit and vegetables). 



872 DISEASES OF THE DIGESTIVE ORGANS. 

From mental excitement: Aconite (anger, fright), Colocyn- 
this (indignation), Ignatia (from grief or indignation), Opium 
(sudden fright), Nux vomica (violent anger; with acute 
jaundice). 



MISCELLANEOUS AFFECTIONS OF THE 
INTESTINES. 

Ulceration of the intestines is of frequent occurrence and has 
already been discussed in connection with diseases of the intes- 
tinal tract. It is practical^ a symptom which demands spe- 
cial consideration and classification because of the frequency 
with which it is seen. 

Primary inflammatory ulceration ma}' occur in the course of 
inflammatory action in any part of the intestine, as an inde- 
pendent lesion or secondary to some other affection, as 
Bright's disease or typhoid fever. It is more common in the 
large intestine and more likely to be found at points where 
there is delay in the passage of fasces (cascum, sigmoid flexure, 
rectum) and where structural peculiarities favor the develop- 
ment of an enteritis. Ulceration resulting from the separation 
of necrosed tissue is seen in connection with amyloid and other 
forms of degeneration and with the so-called peptic ulcer. In 
the intestine, the peptic ulcer is almost alwaj^s duodenal, 
sometimes jejunal; it occurs much oftener in men than in 
women; it is also seen in connection with superficial burns, 
or reasons not yet understood. Ulceration of new growths 
is seen in cancerous and syphilitic growths, tubercular masses, 
etc. Ulcers may be single (duodenum) or multiple (typhoid 
or ulcers of the colon). In the latter form extensive destruc- 
tion of the mucous membrane is common. The peptic ulcer is 
"punched-out," with sharp, well-defined edges, the adjacent 
mucous membrane presenting a normal appearance. Other 
ulcers present irregular, thickened, and often overhanging 
borders with undermining of the adjacent tissues, and a base 
the nature and appearance of which depends upon the layers 
involved or the structures to which it may be joined by inflam- 



MISCELLANEOUS AFFECTIONS OF THE INTESTINES. 873 

matory adhesion. The ulceration of malignant growths pre- 
sents the characteristics of tissues undergoing necrosis, with 
the histological features which belong to the new growth. 
The "old" ulcers of dysentery, typhoid fever and tuberculosis 
consist of ash-gray, pigmented sloughs extending in the long 
axis of the bowel or following the distribution of the lymphoid 
tissues along the course of the blood-vessels and lymphatics. 

Ulceration of the intestine may be acute or chronic. Acute 
ulceration terminates in resolution or goes on to perforation. 
In chronic ulceration inflammatory deposits and adhesions are 
conspicuous features; perforation may take place. Constric- 
tion of the parts from cicatrization in the process of healing is 
frequent and has been discussed in preceding chapters. 

The symptoms are few and not characteristic; they are 
usually overshadowed by the symptoms of the affection of 
which the ulceration is an incident or by the symptoms of con- 
ditions (such as perforation) which may result from it. Ulcer- 
ation may exist and not be suspected during life. Pain is often 
present, but its severity is no indication of the extent of the 
ulceration. Thus a perforating duodenal ulcer may give no 
trouble whatever until perforation occurs or a fatal termina- 
tion is about to take place, while a typhoid ulceration, healing 
perfectly, may be accompanied with intense suffering. The 
passage of bright blood in the stools is of frequent occurrence 
and becomes of diagnostic importance when there is an admix- 
ture of the specific products of the ulcerative process (pus, por- 
tions of tissues, tubercles, cancer cells, etc.). 

Pepper enumerates the following forms of ulceration : round 
ulcers of the duodenum; follicular ulcers (enteritis of chil- 
dren, chronic enteritis of adults, dysentery) ; catarrhal ulcers 
(in the mucous membrane proper) ; stercoral ulcers (from re- 
tention of hardened faecal matter ; most frequent in the vermi- 
form appendix, caecum, sigmoid flexure); ulceration due to le- 
sions without the intestine (tuberculosis or other disease of ad- 
jacent organs); dysenteric ulcer ; ulcer of typhoid fever ; tuber- 
culous ulceration (usually in the lower part of the ileum); syph- 
ilitic ulceration (often transverse or annular); cancerous ulcera- 
tion; toxic ulceration (corrosive poisons); traumatic ulceration 
(from foreign bodies); mycotic ulceration (variola, anthrax, 
actinomycosis) . 



874 DISEASES OF THE DIGESTIVE ORGANS. 

Haemorrhage from the bowels is largely confined to middle 
age, occurs oftener in men than in women, and is rare in chil- 
dren. The term "melaena" is somewhat loosely used to ex- 
press a flow of dark, tar-like blood from the intestine, as 
melaena neonatorum, vomiting and passages from the bowels 
of dark, tar-like blood a few hours after birth, an affection 
which usually proves fatal in a short time. 

The most practical arrangement of the causes of intestinal 
haemorrhage is that by Allchin: a. Increased blood-pressure 
(intense hyperaemia or extreme congestion) ; b. Affections of 
the intestinal wall (injuries of the bowels; ulceration; vascu- 
lar growths and haemorrhoids; amyloid disease of the walls). 

c. Primarily altered blood states (purpura haemorrhagica ; 
leucocythaemia ; yellow fever and severe intermittent fever). 

d. Occasional causes (rupture of aneurism into the intestine; 
vicarious menstruation). 

Symptoms. — If the bleeding is trifling, no constitutional dis- 
turbances are noted ; if severe, they are those of bleeding from 
any other part, i. e., anaemia, faintness, dizziness and pallor, 
with failing pulse, sometimes, as in the present case, with the 
sensation of warm fluid in the bowels. The symptoms due to 
the fundamental affection are usually present. The blood com- 
monly is dark, almost resembling tar, from the action of sul- 
phuretted hydrogen in the intestine upon the haematin of the 
blood. The longer the blood has remained in the intestine, the 
more pronounced this action ; hence, bleeding from the small in- 
testine is characterized by very dark color of the blood. When 
the blood is bright, it may be assumed that it comes from the 
rectum or anal orifice, save in those cases where the haemor- 
rhage is very large and the blood is hurried so rapidly through 
the intestinal canal that this change can be accomplished only 
to a limited extent. Experience has taught that stools cov- 
ered with blood prove bleeding from the colon. 

There may, however, be no external signs of bleeding while 
serious internal haemorrhage is taking place. Cases of fatal 
haemorrhage are on record in which the bleeding was not even 
suspected. There may be increased abdominal dulness. 

The prognosis depends almost wholly upon the general con- 
dition of the patient, especially upon the state of the pulse. 
The loss of a moderate amount of blood mav be of genuine 



MISCELLANEOUS AFFECTIONS OF THE INTESTINES. 875 

benefit in that it equalizes a previously disturbed circulation. 
Trousseau maintained that in typhoid fever, for instance, im- 
provement often follows a moderate internal haemorrhage. 

Treatment. — Absolute rest in bed. Abstinence from food. 
Endeavors to draw the blood to other parts by sinapisms or 
dry cupping. Opium, to stop peristalsis. If the bleeding is 
severe and within reach, injections of equal parts of perchloride 
of iron and water may prove useful ; if from piles, make a direct 
application of a strong solution of the same in glycerine. 
Hamamelis, similarly used, has given good results. If the case 
is urgent, subcutaneous injections of ergotin, two grains dis- 
solved in glycerine, repeated when necessary, may arrest the 
bleeding by producing contraction of the vessels. The use of 
stimulants, though suggested by the general condition of the 
patient, is of questionable value on account of their action 
upon the heart ; they should be exhibited only when absolutely 
indispensable. Injections of very hot or very cold water, ice 
to the abdomen and small pieces of ice swallowed are meas- 
ures which readily suggest themselves. In extreme cases the 
injection of a solution of common salt must not be neglected 
(see Haemorrhage from the Stomach) . 

The following remedies may prove helpful: Belladonna. 
Congestion. Bleeding from the rectum (haemorrhoids). Blood 
bright-red and hot. Sensation of a warm fluid in the abdo- 
men. — Arsenicum. Haemorrhage of dark blood, occurring in 
connection with cancer, typhoid fever, purpura; long-con- 
tinued ; with great restlessness, anxious face and extreme pros- 
tration. — Ipecacuanha. Haemorrhage profuse, bright-red. 
Constant nausea. — Hamamelis. Painless haemorrhage of dark, 
thick blood. Haemorrhoidal bleeding. Fulness and throbbing 
in the rectum. — Carbo vegetabilis. Haemorrhage in connec- 
tion with low fevers, in purpura haemorrhagica and in yellow 
fever; coldness of the extremities, especially of the knees; cold- 
ness of breath pulse thready ; almost collapse. — China is more 
useful in overcoming the effects of heavy loss of blood than in 
controlling the bleeding. It may do good work when the 
patient, especially a person already debilitated by exhausting 
disease or old age, is suffering from ringing in the ears, dizzi- 
ness, faintness, coldness of the extremities, etc. 

Cancer of the intestines is a disease preferably of middle life, 



876 DISEASES OF THE DIGESTIVE ORGANS. 

less frequent than cancer of the stomach. It may be primary 
or secondary. When the latter, it is often due to extension to 
the rectum from the uterus or vagina or to the duodenum from 
the stomach, pancreas or liver. 

The primary growths are chiefly those varieties which are 
found in the stomach (see Cancer of the Stomach). The dis- 
ease usually begins in the mucous and submucous coats, spread- 
ing, and finally involving all the coats of the intestine. More 
rarely, as in the colloid cancer, it extends from without (peri- 
tonaeum) inward. The mesenteric glands are always involved. 
In all forms there is degeneration and ulceration, with inci- 
dental adhesions to adjacent tissues (abdominal wall, uterus, 
adjacent coils of intestine), most marked in the soft varieties. 
The latter may form large masses protruding into the gut, giv- 
ing rise to obstruction. The hard varieties, as scirrhus, grow 
slowly, forming a hard cancerous infiltration. Frequently (in 
scirrhus and encephaloid) the entire circumference of the in- 
testine is involved, constituting an annular cancer which grad- 
ually lessens the lumen of the bowel and may result in oblitera- 
tion of the intestinal lumen. Exceptionally, dilatation is seen 
with the annular growth. Fistulous openings through the 
abdominal wall, abscess-formation and perforation may occur 
incident ally. 

The symptoms are not characteristic and in the early stage 
cannot be recognized, being those simply of indigestion and 
slight intestinal disturbance. Gradual loss of flesh, without 
apparent cause, is often the first intimation of possibly existing 
malignant disease. The existence of intestinal cancer ma} T be 
inferred when cachexia becomes pronounced, with rapidly pro- 
gressing emaciation, tenderness on pressure and soreness at 
some particular spot, abdominal fulness and symptoms point- 
ing to the presence of a tumor, diarrhoea alternating with con- 
stipation, or stubborn constipation, or the band-like stools 
described in connection with constriction of the bowels. Pain 
is rarely present, save when the rectum is involved. 

Malignant disease much oftener involves the large intestine 
than the small, and the rectum about four times as often as it 
does all other parts of the bowel. If in the rectum, the first 
signs are usually found just within the sphincters, in the greater 
number of cases extending upward and downward simultane- 



MISCELLANEOUS AFFECTIONS OF THE INTESTINES. 877 

ously. In due time there is contraction of the parts, often ex- 
treme, with possible and extensive breaking-do wn of the struct- 
ure. Very obstinate constipation exists early, with often 
frightful pain when the bowels move. Eventually the sphinct- 
ers may become practically useless, and then occurs constant 
and incontrollable oozing from the rectum of thin, very offen- 
sive faecal matter. 

The diagnosis is difficult, often impossible, save when located 
in the lower part of the large bowel. 

The prognosis is unfavorable. 

Treatment is surgical ; the physician must endeavor to sus- 
tain the vitality of the patient, lessen the pain, remove the 
offensive odor by the use of disinfectants, and make life endur- 
able. 

Arsenicum, Hydrastis, Kreosote, Conium and Carbo ani- 
malis may aid in meeting these indications. 

Amyloid degeneration occurs in connection with amyloid dis- 
ease in other parts of the organism, usually in the course of 
some disease attended with protracted suppuration, as tuber- 
culosis, syphilis, etc. Involvement of the intestine must be 
considered proof that the disease is far advanced, in fact ap- 
proaching a fatal termination. It first involves the mucous 
layer and gradually progresses until the entire bowel is in- 
cluded in the change. The solitary and agminated glands 
resist for a long time, and may even remain unaffected. The 
appearance of the mucous membrane to the naked eye is that 
of colorless, wet wash-leather, somewhat glistening. It has 
the chief characteristics of amyloid degeneration elsewhere: 
doughy toughness, waxy lustre, vitreous translucency, and 
lack of color. The chemical test alone is decisive (wash the 
surface to be tested so it is free of blood, paint it with a brush 
dipped in an aqueous solution of free iodine ; in a few minutes 
the amyloid matter is colored violet or like mahogany. If 
sulphuric acid is added, the mahogany color changes to blue). 

The symptoms are : chronic, moderate, usually painless, diar- 
rhoea, with slight tinge of blood ; in exceptional cases, free 
haemorrhage. 

The diagnosis depends largely upon the presence of amyloid 
changes elsewhere. 

The prognosis is hopeless and the treatment merely symp- 
tomatic. 



878 DISEASES OF THE DIGESTIVE ORGANS. 

Affections of the mesentery are : haemorrhage, disease of the 
mesenteric arteries and veins, disorders of the chyle vessels, and 
cysts of the mesentery. Of these, haemorrhage is almost always 
associated with bleeding of the pancreas or with retroperiton- 
eal haemorrhage ; it may also occur in rupture of an aneurism 
of the abdominal aorta or superior mesenteric artery and in the 
course of malignant infectious fevers. Diseases of mesenteric 
arteries. Aneurism is very rare and scarcely ever recognized. 
Embolism and thrombosis are more frequent; blocking of the 
superior mesenteric is followed by violent colicky pain, diar- 
rhoea, vomiting and abdominal distension, with fatal termina- 
tion. Resection of the bowel suggests itself as a possibly advis- 
able form of treatment. Dilatation and sclerosis of the mesen- 
teric veins is seen in connection with cirrhosis of the liver. 
Suppuration of the mesenteric veins occurs with pylephlebitis. 
"The mesentery may be much swollen and is like a bag of pus, 
and it is only on careful dissection that one sees that the pus is 
really within the channels representing extremely dilated me- 
senteric veins." Changes in the chyle-vessels usually depend 
upon varicosis or consist of the formation of cysts. They are 
rare and of slight importance to the general practitioner. 
Cysts of the mesentery have of late attracted much attention. 
They may be dermoid, hydatid, serous, sanguinous or chylous. 
In size they range from that of an insignificant enlargement to 
a tumor occupying the entire abdomen. Adhesions may form 
to an}' of the abdominal viscera. The symptoms are those of 
an abdominal tumor of progressive growth, sometimes accom- 
panied with colic and constipation, rarely with loss of general 
health. The tumor is usually situated in the middle line and 
presents no reliable diagnostic points. It has been mistaken 
for ovarian tumor, movable kidney, hydronephrosis and cysts 
of the omentum. Treatment consists of laparotomy and enuc- 
leation of the cyst. 



DISEASES OF THE LIVER. 

CONGESTION OF THE LIVER. 

Reference is made here only to that passive congestion which 
is the result of mechanical obstruction to the outflow of blood 
from the liver. Congestion which is part of a pysiological pro- 



CONGESTION OF THE LIVER. 879 

cess, as digestion, or which occurs in connection with malarial 
and other infectious diseases, will not be considered. 

Etiology. — The causes are local and distant. Constriction 
above (as from a corset), pressure of a tumor upon branches of 
the hepatic vein or obliteration of the hepatic vein by thrombi 
belong to the former. Distant causes are : obstruction of the 
circulation of the blood through the heart (non-compensated 
valvular disease, temporary or permanent weakening of the 
heart muscle) or lungs (bronchitis, fibrous pneumonia, emphy- 
sema, asthma, chronic pleurisy, atelectasis); or in both heart 
and lungs (pressure from malformation of the spine, tumor, 
aneurism, extensive pleuritic effusion on the left side); or com- 
pression of the inferior vena cava from aneurism or tumor. 

Pathology. — A primary symmetrical enlargement of the liver, 
with tense, smooth, shining capsule and great fulness of the 
blood vessels is eventually followed by slowly developing 
atrophy of the liver. The primary enlargement is especially 
marked in the thickness of the organ. The secondary changes 
are chiefly due to derangements of function and nutrition in 
the liver, arising from dilatation of branches of the hepatic 
vein, with hypertrophy of their walls, exerting pressure upon 
the cells immediately surrounding them ; this results in wast- 
ing and disappearance of these cells, whose place is supplied by 
connective tissue of granular appearance, causing increased 
density of the liver and diminution of its size. There is also 
dilatation of the veins supplying the gastro-intestinal mucous 
membrane, with increased density and dark coloring of the 
spleen, pancreas and kidneys. 

Symptomatology. — Local symptoms at first are absent. 
Later, there is in the region of the liver, with the enlargement, 
a sense of fulness and weight, most keenly felt when turning to 
the left side, in bed, or when sitting up. Occasionally there is 
much shortness of breath and pain extending from the liver to 
the right shoulder. Tenderness upon pressure maybe felt. Both 
enlargement and pain are readily aggravated from exertion 
and disappear again after resting. Slight jaundice is common, 
though in many cases both urine and faeces are normal. Symp- 
toms of "biliousness" are common, such as bad taste in the 
mouth, loss of appetite, mild indigestion, headache, dizziness, 
and mental depression. When there is gastro-duodenal catarrh, 



880 DISEASES OF THE DIGESTIVE ORGANS. 

as is common when the heart is affected, the gastric disturb- 
ances may reach considerable severity. 

Plvysical examination shows more or less fulness on the right 
side. Palpation readily detects the enlargement; the finger 
tips of the right hand, pressing inward and upward while the 
abdominal wall is relaxed, can usually locate the lower edge of 
the liver and may even find the notch between the right and 
left lobes. Percussion elicits a flat sound an inch, or more, be- 
low the margin of the ribs, on the right side. 

After the liver has become atrophied, these signs fail; but 
general oedema and ascites are then usually present. 

The diagnosis depends upon the presence of characteristic 
plvysical signs and of such conditions, already enumerated, as 
nmy cause it. The temporal increase of the enlargement from 
exercise and its subsequent lessening from rest are particularly 
noteworthy. 

The prognosis is not good, since the condition depends upon 
causes almost wholly beyond the reach of medical skill. 

Treatment consists of the use of such remedies as are symp- 
tomatically indicated and close attention to an appropriate 
diet. The latter must consist of articles of food both easily 
digested and nourishing. Overeating must be carefully avoided. 
Highly seasoned foods and alcohol in any form are to be ex- 
cluded; meat must be taken in restricted amounts. The occa- 
sional use of mineral waters (Hunyadi, Friedrichshalle, Con- 
gress) is advisable to keep the bowels open. Heart-tonics are 
often called for (Digitalis, Strophanthus, Convallaria, 
Cactus, etc.). 

Therapeutics. — Mercurius solubilis or Merc.dulcis, in the 
low triturations, is perhaps the most valuable remed}^ here, as 
it also is in the state so constantly referred to as "biliousness." 
The tongue is dirty-white, coated heavily, soft and flabby, 
bearing the imprint of the teeth ; breath fetid ; pressive pain 
and soreness in the liver ; liver sore to touch ; abdomen 
swollen; skin looks dirty, icteric. Derangement of the stomach; 
stools greenish-brown, irregular, now almost constipated, then 
liquid and bright yellow. — Nux vomica. Heavy throbbing pain 
in the region of the liver, as from an ulcer ; fine, stinging pains 
in the liver; creeping chills in the region of the liver; 
liver swollen, hard, sensitive; jaundice, with aversion to 



PERIHEPATITIS. 881 

food and short fainting-turns ; useful in persons fond of 
high living, in the habit of using stimulants, of consti- 
pated, hemorrhoidal tendency. — Chelidonium. Enlargement 
of the liver (Burnett: in perpendicular line), with cough 
and pain under the angle of the right shoulder blade ; tongue 
yellowish- white ; bitter taste in the mouth. Sharp, stitching 
pains in the liver, into stomach or back. Tightness and pain 
in the right side during inspiration; abdomen distended and 
sensitive to pressure. Headache, weariness ; anorexia. — Agar- 
icus. Painful dragging as if the great weight of the liver were 
pulling on the ligaments. Sharp stitches as from needles. Dull 
stitches during breathing. Gastric catarrh. Profuse emissions 
of inodorous flatus. — Aurum. Hepatic congestion (enlarge- 
ment) with heart disease; jaundice; pain in the liver; foul, 
putrid taste ; constipation of grayish or ashy- white stools ; 
greenish-brown urine. Burning and cutting in the right hypo- 
chondrium. Characteristic melancholy. — Carduus marianus. 
Hyperaemia of the liver, with sluggish action of that organ, 
with jaundice, constipation, heavy, stupid head, foul tongue, 
fulness and soreness over the region of the liver, sometimes 
with cough ; the tongue is usually furred ; there is usually 
nausea and vomiting of green fluid (T. F. Allen). Liver spots 
on the skin. — Magnesia muriatic a. Slight jaundice (conjunc- 
tivas and face); light-colored gray stools. Tongue large, coated 
yellow, scalloped at the edges. Offensive breath. Sour vom- 
iting. Scanty, albuminous urine. Cannot lie on the right side. 
Tenderness over the region of the liver ; pain extending to the 
spine and pit of the stomach ; weak, small pulse ; stools crum- 
ble as soon as they are evacuated. In puny and rickety chil- 
dren. 

Consult also: Ammonium muriaticum, Euonymin, Podo- 
phyllum, Selenium, Sulphur. 

PERIHEPATITIS. 

An inflammation of that portion of the peritonaeum which 
covers the liver ; it occurs as a circumscribed peritonitis affect- 
' ing only the portion standing in close anatomical relation to 
the liver 'or as a part of a general peritonitis. It may be acute 
or chronic. 
56 



882 DISEASES OF THE DIGESTIVE ORGANS. 

Etiology. — The acute form is usually the result of trauma- 
tism (a blow or cut) or of such injury to the structure as may 
arise from the formation of an abscess or from ulceration or 
perforation of closely related organs (as perforating ulcer of 
the stomach, duodenum, renal abscess, appendicitis, suppurat- 
ing bile-ducts, etc.). It also occurs as a feature of disease of 
the liver itself and as the result of extension of inflammato^ 
action from some neighboring organ (right-sided pleurisy). It 
almost always affects the right lobe, save when resulting from 
splenic disease, as abscess or rupture, in which case the left 
lobe is involved. The chronic (fibrous) form is the outcome of 
persistent irritation, as from the pressure of corsets or from 
habitually maintained bending forward, as is necessary in 
some occupations ; or from the pressure exerted upon the parts 
by growths (cancerous and other nodules); or from exten- 
sion of inflammation from some neighboring organ (chronic 
pleurisy). 

The pathological condition in acute perihepatitis is that of a 
peritoneal inflammation limited to the peritoneal covering of 
the liver and corresponding lower surface of the diaphragm, 
with adhesions between the opposed surfaces. These adhesions, 
more or less complete, may form a pouch containing pus, often 
in considerable amounts (subphrenic abscess), which is ot 
bright-yellow ochre color, from the admixture of bile and bili- 
rubin crystals. The pus cavhVy may also contain gas or air, in 
which case the term "subphrenic p3 r opneumothorax" is applied 
to it. In the chronic, fibrous form the peritonaeum is thick, 
dense, opaque, with band-like adhesions to adjacent organs 
and structures. Globular or lobulated atrophy of the liver 
may result, with narrowing or obliteration of the hepatic and 
portal veins or of the cystic or common bile ducts. 

Symptoms. — The symptoms are those of a peritonitis in the 
hepatic region, with tenderness upon pressure, motion and deep 
inspiration, with fever and slight jaundice. If associated with 
perforation, the local symptoms are intense, with superficial 
breathing and high fever, often preceded by a severe rigor. Loss 
of appetite, nausea and, less often, vomiting ma}- be present. 
The physical signs are distension in the right lrypochondria, 
with dulness on percussion. 

The course of the disease is rapid and favorable, except when 



ACUTE PARENCHYMATOUS HEPATITIS. 883 

it is an incident in the course of some other lesion of grave char- 
acter. If suppuration takes place, the course of the disease is 
tedious and complicated by possible rupture of the sac into the 
lung, stomach or intestine, possibly externally through the 
abdominal wall. The question of drainage then becomes one of 
prime importance. Cicatrization of tissue may result in exten- 
sive contraction of the parts, compressing the portal and 
hepatic veins and bile ducts, and resulting in chronic jaundice 
and ascites. 

Diagnosis. — The physical signs may suggest a pleuritic exu- 
dation, but the absence of cough and expectoration and the 
displacement of the heart, while the symptoms refer to the 
stomach, duodenum and liver, and the pronounced bulging in 
the right hypochondrium, should establish a clear differentia- 
tion. An exploratory puncture (in the seventh or eighth inter- 
space in the axillary line) may be demanded. The presence of 
bile pigment in the pus is characteristic. 

Treatment. — Hot applications (stupes, fomentations, etc.) 
and mustard drafts over the liver, leeches, absolute rest and a 
rigid diet are indicated. The nature of the primary disease 
must receive careful consideration. As soon as the presence of 
pus is established, surgical measures must be employed. In- 
ternal medication is directed to the relief of the inflammation 
and to the control of the suppurative process. 

ACUTE PARENCHYMATOUS HEPATITIS YELLOW 

ATROPHY OK THE LIVER. 

Yellow atrophy of the liver is rare, whether occurring as a 
primary disease or as a secondary affection in the course of 
other lesions of the liver or of constitutional diseases. 

The primary form, with occasional exceptions, attacks 
young adults not over thirty-five years of age, with a prefer- 
ence for women, especially in their later pregnancies. The 
onset is very sudden and extremely violent, and the termina- 
tion fatal. Its causation is as yet a matter of speculation. 
The secondary form is also rare. It is seen in connection with 
cirrhosis or other disease of the liver and in the course of cer- 
tain infectious and constitutional diseases, as typhoid fever, 
recurrent fever, septicaemia, puerperal fever. 

Pathology. — The liver is atrophied to one- third or one-half 



884 DISEASES OF THE DIGESTIVE ORGANS. 

its natural size, very much flattened in shape, looking almost 
like a pan-cake, of flabby, doughy feel, with its capsule 
wrinkled. It is of yellow, saffron-like color, presenting, upon 
section, irregularly distributed alternating patches of red and 
yellow. The condition is one of fatty degeneration of the 
hepatic cells of the entire organ. The fatty matter being 
readily absorbed b} r the lymphatics, eventually only the blood 
vessels and connective tissues are left. When the former are 
congested, as is commonly the case, they form the red spots 
described. Crystals of leucin and t^-rosine may- be seen in the 
tissues after exposure to the air. 

In connection with these changes in the liver, fatty degenera- 
tion takes place also in the kidneys, heart and, less often, in 
the (voluntary) muscles. Enlargement of the spleen is always 
present. The skin and tissues of the body are tinged with bile. 
There are small haemorrhagic effusions in the gastric and in- 
testinal mucous membrane, in the serous membranes of the 
kidneys, sometimes in the brain and heart. The serous cavi- 
ties contain an excess of fluid. 

Symptoms. — The prodromal stage, which in some cases is 
wholly wanting, consists of languor, indisposition, loss of 
appetite, gastric uneasiness with belching, nausea and some- 
times vomiting, slight headache, slight jaundice, and occasion- 
ally moderate fever. The second stage, which often marks the 
first noticeable deviation from health, begins with a decided 
aggravation of the jaundice and a train of nervous symptoms 
of extreme severity from the very first. There is violent head- 
ache, with much restlessness and insomnia, with dulness of 
intellect, slow and indistinct articulation, and rapidly develop- 
ing, extremely violent delirium, with local spasms and, rarely, 
general convulsions. After one or two days the violence of 
these symptoms abates, the patient quiets down, drifts into a 
state of sopor which develops into profound coma and ter- 
minates in death. The pulse at first is slow, then variable, 
and at last rapid and weak. There is little, if any, fever. A 
decided rise of temperature, to 106°, or more, or a fall to sub- 
normal, usually precedes death. Haemorrhages from the 
stomach, bowels, nose, kidneys, female genitalia or skin are 
always present and persistent. The urine usually is scant}', 
sometimes suppressed, acid, and of increased specific gravity. 
It is slightly albuminous, strikingly deficient in urea, and con- 



SUPPURATIVE HEPATITIS. 885 

tains bile pigments, bile acids, creatine, leucin, tyrosine, and 
hyaline and fatty casts. Vomiting may be severe, especially 
when the brain symptoms first appear. The stools are clay-^ 
colored and hard. In the case of a pregnant woman, abor-' 
tion, with excessive flooding, is almost sure to occur. 

The physical signs consist chiefly of a progressively diminish- 
ing area of dulness in the region of the liver. This is not so 
noticeable at first, and it may be absent in cases which 
rapidly progress to a fatal termination. Attention has been 
called to a tenderness in the region of the liver which is so ex- 
quisite that the patient, even in coma, manifests pain from 
slight pressure. 

The duration of the first stage varies ; the second stage, 
counting from the appearance of the cerebral symptoms, lasts 
from two to four or five days, not often longer. 

The termination is invariably fatal. 

Diagnosis. — The first stage is as free from characteristic 
symptoms as the second is marked. In the latter a mistake 
can hardly be made, except as phosphorus poisoning might be 
suspected. 

Poisoning- -with phosphorus has more pronounced gastric 
symptoms ; the liver remains of normal size for a longer 
period ; hepatic pain and tenderness are usually more intense ; 
the brain symptoms set in earlier (if the prodromal stage is 
counted); there is less maniacal delirium, and the urine con- 
tains little, if any, leucin and tyrosine. 

Treatment consists of such relief as may be afforded by ener- 
getic attempts to control the vomiting (ice by the mouth; 
morphia?), application of cold water to the head, and stimu- 
lants when required. 

We know of no remedy offering clinical proof of value in this 
condition. Phosphorus naturally suggests itself as an almost 
similimum, but I know of no case of yellow atrophy of the 
liver which was cured by it. Lachesis, Arsenicum and 
Belladonna deserve careful study. 

SUPPURATIVE HEPATITIS-ABSCESS OF THE 
LIVER. 

^Etiology. — Abscess of the liver is a disease of adult life, 
rarely occurring in the very young or in the aged ; it attacks 
women in only five or ten per cent, of all the cases. It is due 



886 DISEASES OF THE DIGESTIVE ORGANS. 

to the action of pyogenic, infectious irritants (bacteria; amoe- 
bae; chemical?), which may invade this organ in connection 
with traumatism or are carried to the liver from other organs 
by means of the blood vessels or bile ducts. Of the blood ves- 
sels, the portal vein is particularly active in gathering, 
through its tributan^ vessels, disease products from various 
structures and organs, eventually depositing them in the liver ; 
thus almost any disease, especially suppurative processes, 
within the structures reached by its ramifications may furnish 
the material from the action of which results hepatic abscess. 
It is, however, an abundantly demonstrated fact that of all 
the possible causes of infection, including the ulceration of 
tuberculosis and typhoid fever, the products of dysenteric 
ulceration are especially liable to produce this lesion. Waring's 
tables show that dysentery had existed in about three-fourths 
of all the cases collected by him. Nevertheless, as stated, other 
diseases of the intestines, especially of the large intestine, such 
as typhlitis, proctitis, haemorrhoids or even trauma from oper- 
ations, may be followed by hepatic abscess. 

The hepatic artery becomes the channel of infection in case 
of suppurating wounds of the head and in such processes as 
ulcerative endocarditis, putrid bronchitis, suppuration about 
an aneurism, etc. Embolism of the hepatic artery perse is an 
infrequent cause, although a bland embolism may be the start- 
ing point of an abscess if carried to some part of the liver 
where pyogenic factors alread3 r exist. The hepatic vein may 
also, but more rarely, carry infection. 

The bile ducts perform a similar office in case of intestinal 
affections, especially when there is gastro-duodenal catarrh. 
The presence of foreign substances, as gall stones, giving rise 
to local necrosis from pressure and to retention and decompo- 
sition of bile, greatly facilitates the process. Extension by con- 
tiguity of structure is a factor of importance in some cases. 

Traumatism in the hepatic region is of less practical import- 
ance than would appear at first glance. Extensive injuries to 
the liver (brakemen in coupling cars, gun-shot wounds) have 
recovered completely without suppuration. 

The tropical abscess is a frequent and dangerous disease pe- 
culiar to hot climates (India); it shows a special preference for 
Europeans who indulge in careless and high living. It usually 



SUPPURATIVE HEPATITIS. 887 

follows dysentery, but may be idiopathic. Cases of it are 
not infrequent in our Southern states. 

Pathology. — In the great majority of cases seen in the tem- 
perate climates numerous small abscesses are found, which 
upon section prove little pockets of pus directly communicat- 
ing with the portal vein, and which in reality are distended 
and suppurating branches of the same. This suppuration in- 
volves large portions of the liver, and may include the entire 
portal system of the liver, save as blocking by thrombi pro- 
tects parts of it. The hepatic parenchyma is destroyed. Con- 
fluence of many small abscesses into one large pus cavity is 
common; these often contain enormous quantities of pus, even 
two or three quarts. The pus may be laudable or fetid and 
bile-stained. 

The liver itself is uniformly enlarged ; its capsule is tense and 
smooth; sometimes it is almost normal in appearance; in 
other cases it shows the underlying numerous abscesses as fine 
white points. 

The large single abscess constitutes a large pus cavity, with 
indistinct -walls made up of necrosed liver tissue, pus cells and 
amoebae, kept within check by slowly yielding hyperasmic liver 
tissue. It contains grayish-white, creamy or reddish-brown 
pus of peculiar odor. It may involve the greater portion of 
the liver, and is usually situated near the convexity of the 
right lobe. 

Abscesses may become encapsulated and, if small, even ab- 
sorbed. The tendency, however, is to perforation. This may 
take place into the abdominal cavity, followed by diffusive per- 
itonitis, or through the diaphragm into the lungs or bronchi. 
Or the abscess may empty into the stomach, intestine, peri- 
cardium, or pelvis of the right kidney. A frequent and very 
favorable occurrence is the escape of pus through the abdomi- 
nal walls after inflammatory adhesion between these and the 
liver has taken place. 

Symptomatology. — The symptoms of suppurative hepatitis 
lack in characteristic distinctness, and extensive abscesses have 
often been seen after death when no indication of their pres- 
ence existed during life. Again, it may be difficult to distin- 
guish and properly classify the symptoms which are local and 
those which arise from the involvement of neighboring organs. 



888 DISEASES OF THE DIGESTIVE ORGANS. 

Small abscesses rareh' give rise to symptoms of sufficient in- 
tensity to be noticeable. 

Enlargement of the liver is common, being situated, usually, 
near the convexity of the right lobe. "If the abscess occupies 
the posterior portion of the right lobe, the liver is pushed 
down so that its margin is perceptible below the free border of 
the ribs, and the flatness on the right side, posteriori}", extends 
higher than normal. If the abscess is superficial and is point- 
ing externally, a distinct tumor is felt, and there is almost al- 
ways more or less bulging of the ribs if the right lobe is 
affected. Sometimes the organ is enormously enlarged, its free 
border extending below the umbilicus ; the surface of the en- 
largement is smooth, and it is usually tender on pressure. The 
sensation to the examiner on making light pressure will be 
soft and fluctuating, or that of elastic tenseness" (Loomis). 
Osier emphasizes an "increase in the volume upward and to 
the right, not downward, as in cancer and other affections pro- 
ducing enlargement." Dullness usually begins at the level of 
the fourth or fifth rib. 

Pain is localized, and generally consists of a dull, heavy, 
dragging pain across the trunk, which obliges the sick to lie on 
the right side or on the back, preferably the former. There is 
often a characteristic pain at the tip of the shoulder or at the 
angle of the shoulder blade, which is present when the con- 
vexity of the liver is involved. Often the pain is superficial ; in 
the presence of a localized peritonitis it is associated with ab- 
dominal tenderness and tenseness of the rectus muscle. Fever 
is irregular, intermittent, with occasional chills and copious 
sweating, especially when sleeping. The temperature may be 
normal, even sub-normal, then suddenly rise to 102°, or more. 
It closefy resembles malarial fever. Jaundice usually is not 
marked, and occurs in a pronounced form only when there is 
compression of some large biliary duct ; it is seen in about six- 
teen per cent, of all the cases. Pressure upon the portal vein 
causes ascites. 

The constitutional symptoms are : malaise ; loss of appetite, 
nausea, vomiting ; progressive loss of flesh and strength ; diar- 
rhoea or constipation, irregularity of the bowels being a com- 
mon feature ; increased frequency of the respiration ; more or 
less dry cough; mental depression, nervousness, wakefulness, 



SUPPURATIVE HEPATITIS. 889 

stupor, coma, death. A sallow, almost cachectic, appearance 
of the face is peculiar to the disease. 

In case the lung becomes involved from extension, not rup- 
ture, through the diaphragm, a pleurisy develops, with reddish- 
brown expectoration (blood pigment, blood corpuscles, haema- 
toidin) containing large numbers of amoebae coli, such as are 
found in the liver abscess and stools. 

The duration of suppurative hepatitis, as well as its termina- 
tion, is influenced by the primary cause of the disease. The 
average case continues from six weeks to two or three months. 
If due to pyaemia, the course is rapid and toward a fatal termi- 
nation ; in idiopathic cases and in those due to gall-stone, it is 
very tedious. 

The prognosis must always be guarded. A single, small 
abscess may be absorbed or rendered harmless by calcification, 
but a large number of small abscesses render a prognosis 
doubtful, unless they become confluent and thus amenable to 
operative treatment. Cases due to pyaemia, and with perfora- 
tion into the peritoneal cavity, are practically hopeless. As a 
rule, emptying of the abscess externally or into the intestine or 
bronchi vastly increases the chance of final recovery (about fifty 
per cent, of all cases), but even here death may occur from 
complete exhaustion or from some complication, as haemor- 
rhage, peritonitis or septicaemia. Since operative measures 
have been introduced into the treatment of hepatic abscess, 
the percentage of recoveries, according to Fitz, has risen from 
thirty to eighty per cent. 

Diagnosis. — Intemperate climates the diagnosis rests largely 
upon the recognition of primary causes, such as dysentery, and 
upon the actual demonstration of the presence of pus in the 
liver. Hence, in all suspected cases an exploratory aspiration 
is indicated, to be performed with a large aspirator needle, the 
patient under anaesthesia. The needle should enter in the 
anterior axillary line in the lowest interspace, or in the sev- 
enth interspace in the mid-axillary line, or over the center of 
the area of dulness behind. The exploration may have to be 
repeated several times ; failure to demonstrate the presence of 
pus is not conclusive evidence of its non-existence in the liver. 

Malarial fever resembles hepatic abscess, but it has pro- 
nounced splenic enlargement and is almost sure to be favor- 



890 DISEASES OF THE DIGESTIVE ORGANS. 

ably affected by quinine. In doubtful cases the presence of the 
characteristic micro-organisms will determine the diagnosis. 
Hepatic fever of gall-stone has paroxysms of fever with sweat, 
which are regular, though often separated by long intervals ; 
the paroxysm is followed by increased jaundice; the general 
condition of the patient is not one of decline, as in hepatic 
abscess ; on the contrary, the intervals between the attacks 
are marked by excellent health. 

Treatment. — The general aim of treatment is to keep the 
patient in the most favorable condition possible until pus has 
formed and can be evacuated. If the abscess has emptied itself, 
further operative measures will be deferred until indicated by a 
reaccumulation of pus. In case of the large, single abscess this 
treatment almost always gives prompt relief. When there is 
pyaemia or suppurative phlebitis, surgical interference, like all 
other methods of treatment, is absolutely useless. To keep 
the patient reasonably comfortable, hot or cold applications 
or sinapisms over the liver, at times dry cupping, have proved 
advantageous. The bowels should be kept open by appro- 
priate diet and the use of saline waters. Food should be 
nourishing, but chiefly liquid, such as milk, whe3 r , broths, 
gruels, beef-juice, and soft toasted bread. 

Hepatic abscess is a surgical disease and internal medica- 
tion, though possibly helpful, is of relatively small importance. 
Remedies which may prove useful are : Bryonia, Chelidonium, 
Mercurius sol., Phosphorus, Hepar sulphur, and Hypo- 
phosphite of LIME. 



FIBROUS HEPATITIS-CIRRHOSIS OK THE LIVER- 
CHRONIC INTERSTITIAL HEPATITIS. 

A chronic disease of the liver, characterized by an increase in 
the connective tissue, with gradual destruction of the liver 
cells, in the course of which process the liver becomes hard- 
ened, undergoes a diminution in size, and assumes a granular, 
hob-nailed appearance. 

./Etiology. — Cirrhosis of the liver is a disease of middle-aged 
men ; it rarely occurs in children, except as a feature of S3 r phi- 
litic disease, and only exceptionally in women. The following 



FIBROUS HEPATITIS. 891 

are the chief astiological factors : In more than one-half of all 
the cases the abuse of alcoholic liquors, especially of liquors 
rich in fusel-oil, as those made from grains and potato (drunk- 
ard's liver; gin-drinker's liver); this is said to apply particu- 
larly to persons who are in the habit of taking liquors with- 
out previously diluting them with water. It is asserted, but 
without sufficient proof, that the free use of spices, as curry, 
has a similarly irritating effect upon the liver. Syphilis ranks 
next, especially in the cases found among children. Certain in- 
fectious (scarlet fever, typhoid fever, tuberculosis, malaria, 
cholera) and constitutional diseases (rickets), presumably by 
infection of the liver through the blood. Diseases of other or- 
gans which give rise to passive venous congestion in the liver, 
as chronic diseases of the heart and lungs. Extension, occasion- 
ally, of a chronic perihepatitis into the substance of the liver. 
Chronic inflammation of the bile ducts, from gall stones, 
tuberculosis, or obstruction or obliteration of the bile ducts 
from any cause. Mechanical irritation, as from the presence of 
coal dust in the liver, an affection which is occasionally found 
among miners ( anthracosis ) . 

Morbid Anatomy. — The essential feature is the overgrowth 
of the connective tissue elements, resulting in compression and 
atrophy of the liver cells, and obstruction of the blood vessels. 
The size of the liver varies. In some forms extensive hyper- 
trophy exists, and the weight of the liver may reach eight or 
nine pounds. Others are characterized by extreme atrophy, 
the weight of the organ perhaps not exceeding one pound ; but 
the overgrowth of connective tissue is always present. 

Three forms may be distinguished : the atrophic, the hyper- 
trophic, and fatty cirrhosis. 

Atrophic cirrhosis. The liver is much reduced in size ; it may 
weigh as little as a pound or pound and a-half; its substance is 
hard and tough. The surface is roughened and shows many 
granulations, varying in size from a poppy-seed to a hazel nut 
(hob-nailed liver). On section, it appears to be made up of 
yellow islets, the remains of liver tissue, imbedded in white 
translucent connective tissue. It is because of this yellow 
color of the liver that Laennec called the disease "cirrhosis." 
In the so-called Glissonian cirrhosis the liver is inclosed within 
a much thickened, sometimes almost cartilaginous, grayish- 



892 DISEASES OF THE DIGESTIVE ORGANS. 

white capsule, which can readily be stripped off the hardened 
atrophied cirrhotic gland, exposing a granulated, at times 
smooth, surface. The degree of the atrophy differs, as does 
also the shape of the organ and the extent to which the essen- 
tial changes have taken place. Sometimes the left lobe almost 
completely disappears ; again the changes may be more pro- 
nounced in some parts of the liver than in others ; thus, at the 
sharp edge of the liver there may be nothing left but a semi- 
transparent tissue, containing none of the elements of the 
gland. The atrophic form is by far the most common, and 
usually follows the abuse of alcoholic liquors or, less often, ob- 
struction in the portal circulation. 

The hypertrophic form is characterized by permanent en- 
largement of the liver ; the number and form of the liver cells is 
not so materially affected as in atrophic cirrhosis ; the organ 
itself is firm and tough, with smooth surface and, on section, 
of deep greenish-yellow color. 

Fatty cirrhosis presents a smooth surface of the liver; the 
gland is pale, anasmic, slightly granular, of 3 T ellowish-white 
color. It somewhat resembles fatty liver, but is firm and 
tough in consistency and presents the characteristic over- 
growth of connective tissue. It is said to be a disease of beer- 
drinkers. 

Adhesions may form between the capsule and the peritoneal 
covering of the diaphragm. The peritonaeum is thickened, 
opaque, and there may be tuberculous peritonitis. Ascites 
and gastric and intestinal catarrh are common ; the spleen is 
enlarged and dense. Obstruction in the portal circulation, 
caused by the pressure arising from the excess of connective 
tissue, necessitates compensatory circulation which is carried 
on by dilatation of the anastomoses between the portal sys- 
tem of veins and those of the vena cava. 

Symptoms. — Atrophic Cirrhosis. — The prodromal stage is 
indistinct. It consists of such symptoms of gastric catarrh, 
i. e., anorexia, indigestion, nausea, vomiting, etc., as result 
from the alcoholic habit ; among these morning sickness is 
especially pronounced. There may be pain in the liver, but 
characteristic symptoms do not arise until there is consider- 
able disturbance 'in the portal circulation. It is on this 
account that the establishment of an ample compensatory 



FIBROUS HEPATITIS. 893 

circulation is of such vast importance ; this being efficiently 
maintained, there will be slight, if any, constitutional disturb- 
ance. 

Ascites, arising from stasis in the peritoneal veins, may occur 
at any time after failure of the compensatory circulation, and 
may be the first symptom brought to the attention of the 
physician. It is rather slow in development, but progressive, 
and is accompanied with corresponding abdominal distension 
and such difficulty of breathing as results from the upward 
pressure of the effusion. The amount of the effusion is some- 
times enormous, possibly from fifteen to twenty quarts. 

Enlargement of the spleen is a constant symptom, though 
not easy of detection when there is much ascites. It is in pro- 
portion to the obstruction in the portal circulation. Palpa- 
tion more frequently than any other method determines the 
extent of the splenic enlargement. 

Gastric and intestinal catarrh exist throughout the course of 
the disease, but, unless very pronounced, may not attract 
much attention, for the patient in nearly every case has for a 
long time suffered from it as an early result of alcoholism. The 
bowels are irregular, sometimes constipated, then loose. Often 
there is active diarrhoea; if so, it should not be suddenly 
checked, since it constitutes a source of relief to the patient. 
Chronic venous congestion in the stomach and intestines gives 
rise to bleeding, and often haemorrhage from the stomach, 
sometimes quite copious, appears early in the course of the 
affection ; at other times bleeding occurs from the intestines 
(preferably the small), or an oozing of blood may take place, 
and is then shown in bloody coating of the stool. The liver is 
usually somewhat enlarged in the early stage, but later be- 
comes atrophied. Palpation will detect the lower border and 
its growth in many cases may be watched from week to week 
until the occurrence of dropsy renders further observation im- 
possible. After the performance of paracentesis a thorough 
inspection of the liver again becomes possible. If the irregu- 
larities on the surface can be detected, recognition of the dis- 
ease is made comparatively easy. If the liver is contracted, 
its edges may sometimes be felt in the epigastrium and just 
behind the costal cartilage. 

Constitutional symptoms become pronounced as the case 



894 DISEASES OF THE DIGESTIVE ORGANS. 

progresses. Respiration grows labored and somewhat embar- 
rassed from the upward pressure of the peritoneal effusion ; the 
action of the heart from the same cause becomes rapid and 
feeble. Slight jaundice is frequently present, but is rarely 
severe, save when the intra-hepatic bile ducts are occluded. 
There is oedema of the legs, scrotum and other dependent 
parts, and the patient gradually assumes the appearance 
peculiar to persons suffering from serious liver trouble. Ema- 
ciation is great ; the face is pinched and haggard, with cheeks 
hollow and eyes sunk ; the skin is dry, ashen, scaly ; the tongue 
coated and dry. The chest appears flat and hollow, in strik- 
ing contrast to the distended, protruding abdomen. Through- 
out there is little, if any, fever, except as fever may arise from 
some complication. The urine is at first normal ; later it be- 
comes dark, scanty and rich in urates, with bile pigment when 
there is much jaundice. Ecchymoses under the skin or into the 
mucous membrane, sometimes into the retina, may be seen in 
the later stage. Exhaustion finally becomes extreme, and 
death occurs from exhaustion, from some acute complication 
(pneumonia, pleuritis, peritonitis) or from degeneration of the 
heart or kidne} r s. 

Hypertrophic cirrhosis is characterized by chronic and great 
enlargement of liver, with jaundice which may appear sud- 
denly or may have existed for a considerable length of time 
without creating serious disturbance. All at once the symp- 
toms of an acute febrile jaundice declare themselves, with 
delirium, dry tongue, rapid pulse, high temperature (102° to 
104°), petechia?, even convulsions, constituting a picture of 
acute yellow atrophy, death occurring two or three weeks 
after the onset of these symptoms. 

The course of the disease is progressive, and the termination 
usually fatal within a year after the symptoms of obstructed 
portal circulation (haemorrhage, ascites) have appeared. 
Nevertheless, even in bad cases marked and lasting relief may 
follow tapping or the occurrence of a free haemorrhage. 

Diagnosis. — The diagnosis depends upon a history of indul- 
gence in alcohol, presence of gastric catarrh, size of the liver 
and spleen, occurrence of haemorrhage from the stomach and 
bowels, and ascites. Thrombosis of the portal vein may exist 
and is recognized by the rapidity with which ascites develops. 



FIBROUS HEPATITIS. 895 

Syphilis is recognized by its history and the evidence of syphi- 
litic disease presented by other organs, as the throat. Chronic 
or tubercular peritonitis have neither jaundice nor splenic en- 
largement ; the face lacks the ashen color peculiar to diseases of 
the liver ; there is more fever, and, in case of tubercular disease, 
the specific micro-organisms can be found. 

Treatment. — If the case is seen early, the use of alcohol in 
any form, and of spices, coffee, etc., must be positively pro- 
hibited. The patient must be kept out of doors, exercising 
freely and regularly, but stopping short of fatigue ; pains must 
be taken to keep the skin and the kidneys in a healthful condi- 
tion, being cautious also to protect the patient against getting 
cold or wet. The diet should be nourishing and easily digested. 
Milk may be used liberally. Vegetables (with the exception of 
potatoes), eggs, lean meat, boiled fish and fruits are allow- 
able. Saline waters are very useful at any stage. 

If seen in the later stages, the chief task lies in maintaining 
the strength of the patient and in meeting emergencies as they 
arise. Such remedies as will favorably affect ascites may be 
used, but almost always paracentesis must be performed 
sooner or later. German physicians advise that tapping be 
done early and repeated when necessary. The use of an elastic 
abdominal bandage is thought to delay the reaccumulation of 
the fluid. Haemorrhage is not often serious, often positively 
helpful in its secondary results, and practically beyond reach 
(ice; secale?). When the strength of the patient gives way 
completely, it may be necessary to use stimulants. 

Therapeutics. — To what extent medication may influence 
the overgrowth of connective tissue which is the cause of the 
entire train of symptoms is as yet an unanswered question. — Nux 
vomica, as shown by reliable and extensive clinical experience, 
holds a close curative relation to many important results of 
the alcohol habit, and should prove of value in at least the 
early stage of cirrhosis. The same applies to Arsenicum, 
which covers the gastric catarrh and many of the liver and 
spleen symptoms, to say nothing of its relation to dropsy or 
its action in cases where malarial influences have been at 
work. The presence of ascites suggests Apis, Apocynum, Ar- 
senic, Elaterium, Mercury. Mercury, Bryonia, Chelido- 
nium, Carduus, Nitro-muriatic acid and Podophyllum may 



896 DISEASES OF THE DIGESTIVE ORGANS. 

be indicated, especially in the early stage. Potassium iodide 
and Mercury are suggested by the presence of syphilitic 
symptoms. 

FATTY LIVER. 

The normal liyer contains considerable fat, nearly four per 
cent, of its weight. Under certain circumstances, as after eat- 
ing freeh' of rich, fat food, a temporary increase of fat in the 
liyer takes place, which may become excessive when such indul- 
gence is habitual and occurs in persons who shun physical ex- 
ertion ; this is fatty infiltration, a process which in itself is not 
pathological, although, it may give rise to inconvenience and 
even disturbance of health. 

Under certain circumstances, however, the cell-protoplasm of 
the liver is destroyed and fat takes its place ; this is a patho- 
logical, degenerative process, known as fatty degeneration. 

./Etiology. — As stated, fatty liver may be the result of 
habitual high living or of gluttony combined with physical 
laziness. An abnormally large amount of rich food is taken 
into the system, carried to the liver, and is there left to accu- 
mulate. The liver is not at fault. 

Chronic wasting diseases, like phthisis and extreme anaemia, 
give rise to fatty liver, presumably because of resulting failure 
to complete the process of blood oxidation. The same cause, 
i. e., deficient oxidation, is operative in chronic alcoholism, in 
some cases of chronic diarrhoea, rickets and malaria. Phos- 
phorus-poisoning also causes fatty degeneration of the liver. 

Pathology. — The liver becomes uniformly enlarged, some- 
times attaining great size, with smooth surface and round 
borders. It is pale, bloodless, doughy, and pits on pressure. 
On section it is dry; put upon a piece of blotting paper, it 
leaves a grease-spot ; fat is left upon the knife used in cutting 
it. When thrown into water, the liver floats. 

The microscope shows that in light cases the fat globules are 
limited to the outer zone of the lobules near the portal vessels ; 
in more extensive cases the entire organ is involved. 

Symptoms. — The symptoms are not characteristic. Physical 
examination will determine the degree of enlargement of the 
liver, provided the subject is not obese ; in case of emaciation 



AMYLOID LIVER. 897 

from wasting disease the enlargement is readily recognized. 
There is no pain or jaundice. Exceptionally the portal circula- 
tion is somewhat interfered with, and then gastric catarrh is 
present. Sometimes the patient is troubled with haemorrhoids. 
Very fat people may suffer a good deal from respiratory em- 
barrassment and palpitation of the heart, especially upon ex- 
ertion, etc., but these symptoms are not the result of the 
hepatic disorder. When fatty liver is associated with a pro- 
found constitutional disease, the symptoms of such affection 
are, of course, present. 

The diagnosis depends upon the existence of such habits or 
disease as in themselves suggest the possibility of fatty liver 
and upon the negative character of the hepatic symptoms (as : 
absence of pain, hardness, jaundice, splenic enlargement, etc.). 
Addison considered a bloodless, waxy appearance of the skin, 
which to the touch gives the impression of smoothness and 
laxity, characteristic of fatty liver. 

Treatment. — A life of activity in the fresh, open air; modera- 
tion in eating and drinking; a diet limited to a reasonable 
amount of good, wholesome food, avoiding fats, sugar and 
starch ; living in cool rooms ; abstinence from alcoholic drinks, 
ale, beer, and champagne ; free use of the cold sponge or plunge 
bath — these constitute the treatment of cases arising from 
high living and obesity. When a feature of wasting disease, 
the treatment must be that of the fundamental disease. 

Of remedies, Phosphorus, theoretically, promises most; 
Bayes claims to have had good results from it. — Arsenic and 
Iodoform should also be of service, since they in the provers 
cause symptoms of fatty degeneration. There is, however, no 
reliable clinical evidence to sustain any claim made in their 
behalf. 

AMYLOID LIVER. 

Amyloid, waxy, lardaceous liver occurs in connection with 
chronic suppurative processes and low, cachectic states, as 
scrofulous, tuberculous and syphilitic diseases, especially of the 
bones and joints. Its essential causes are not known. 

Anatomy. — The liver is much enlarged, even to twice its 
normal size, and is hard, inelastic, resistant, with smooth and 
glistening capsule. It cuts like bacon ("lardaceous" liver). 
57 



898 DISEASES OF THE DIGESTIVE ORGANS. 

When cut, the organ appears of grayish or yellowish color, 
"waxy," a little blood often exuding from the cut surface. A 
thin slice of liver, held up to the light, transmits the light. 
The application of a solution of iodine changes the color of the 
surface to a brownish red, mahogany color. Evidence of co- 
existing cirrhotic, fatty or syphilitic disease is frequently 
found. The spleen and kidneys are often implicated. 

Symptoms. — The large, resistant and smooth hepatic tumor 
can be made out hy palpation. There is no tenderness to pres- 
sure, no pain in the liver, no jaundice. If the enlargement is 
great, abdominal fulness and distension are felt, and the 
patient may suffer somewhat from symptoms of gastric 
catarrh. Enlargement of the spleen may be detected by pal- 
pation in the left hypochondrium. Dropsy, beginning in the 
legs and extending into the serous cavities, is the expression of 
renal involvement and of profound cachexia. The stools often 
are clay-colored and frequent. There is no fever. 

The diagnosis depends upon the painless enlargement of the 
liver, occurring in connection with the morbid states enumer- 
ated, with renal and splenic complications. 

The duration is indefinite, from months to years ; the prog- 
nosis is unfavorable. 

Treatment consists of measures directed to the primary dis- 
ease and of such regimen as will best maintain the strength of 
the patient. A life in the open air, good nourishing diet, cloth- 
ing which will insure an even bodily temperature and prevent 
taking cold, a healthful condition of the skin, and caution in 
the use of alcohol, constitute nearly all that can be done. 
Iodine in some form appears to exert a favorable effect upon 
the process ; the potassium iodide will prove particular^ use- 
ful when there is syphilitic taint. Mineral waters containing 
iodine should be persistently drunk (Kreutznach, Woodhall 
Spa, etc.). Thermal baths are also highly recommended (the 
hot baths of California, Colorado, New Mexico, Virginia, 
Arkansas, etc.; in Europe, Aix-la-Chapelle, Ems, etc.). 



MORBID GROWTHS. 

Malignant disease of the liver consists of cancerous or sarco- 
matous growths, with enlargement of the organ, irregularity 



MORBID GROWTHS. 899 

of its surface, usually severe pain, cachexia, etc., and in the 
greater number of cases, rapidly fatal termination. 

Cancer of the liver is a disease of middle age (from 40 to 60 
years of age) and occurs oftener in men than in women, al- 
though the frequency with which secondary cancer is seen in 
the liver of women suffering from cancer of the uterus must 
not be overlooked. Heredity is an important factor. 

Primary cancer occurs in about one-fourth of all the cases. 
It may be massive, appearing in large masses involving a con- 
siderable portion of the liver, as a grayish-white formation, 
rather hard and distinctly outlined. The nodular form consists 
of nodules irregularly scattered throughout the organ, with 
usually a primary or parent formation, easily recognized, from 
which the secondary nodules have sprung. In another and 
rare form cirrhosis of the liver is present ; the surface of the 
gland is yellowish-gray and studded with nodular, yellowish 
masses, surrounded by fibrous tissue, which upon section are 
seen in abundance throughout the organ. 

Secondary cancer is usually found in masses which may 
reach immense proportions and give rise to great enlargement 
of the liver, the organ weighing twenty pounds, or more. 
When near the surface of the liver the cancer-nodules give to it 
an easily detected irregularity of surface. The nodules are 
usually flattened and have a central depression ("cancer 
navel"); they may be disseminated equally throughout the 
liver or may involve only one lobe. Their appearance on sec- 
tion is grayish- white or reddish- white, or dark red if there has 
been much extravasation of blood. Extensive degenerative 
changes may take place. Fatty degeneration is comparatively 
frequent ; hyaline transformation may occur ; it changes large 
areas into a dry, dense, grayish-yellow mass. Haemorrhage 
and suppurative processes are common. 

The bile passages are subject to cancerous disease, usually 
the result of irritation from the presence of calculi, which first 
attack the fundus of the gall-bladder, then the common hepatic 
ducts and contiguous structures. 

While true cancer is by far the most common form of malig- 
nant growths seen in the liver, sarcoma is found occasionally, 
especially melanotic sarcoma. This is almost always sec- 
ondary to sarcoma of the skin or eye. The liver is enlarged, 



900 DISEASES OF THE DIGESTIVE ORGANS. 

and upon section presents a dark, more or less uniformly mot- 
tled appearance, like dark granite or marble. Angioma are 
comparatively frequent ; they consist of small reddish bodies, 
not often exceeding the size of a walnut, made up of dilated 
vessels. 

Symptoms. — Until far enough advanced to occasion consid- 
erable enlargement, no symptoms may be present ; in fact, to 
a certai* extent the presence of s\ r mptoms depends upon the 
size of the cancerous growth. In some cases, however, moder- 
ate gastric uneasiness, loss of appetite, nausea and vomiting, 
with lassitude and loss of flesh and a tendency' to constipation, 
are made the subject of complaint. Pain may, or may not, be 
felt; if present, it varies in intensity and, when severe, radiates 
from the liver in different directions. Jaundice is seen in about 
one-half of all the cases, with or without colored stool ; it is 
rarely marked unless there is occlusion of the common bile 
duct. Ascites is infrequent, except in the cirrhotic form ; pres- 
sure upon the portal vein or peritoneal involvement causes 
dropsy. Fever is slight. In many cases there is practically no 
elevation of temperature, while in others a continuous eleva- 
tion, reaching 101° or 102°, may exist. Pus-formation natur- 
ally causes a rise in the temperature. The urine is scanty, high- 
colored, slightry albuminous. In melanotic sarcoma it is dark, 
blackish, from the presence of melanin ; or it may assume this 
color after standing or when heated with nitric acid, from the 
presence of melanogen. 

Inspection shows an enlargement of the liver which in excep- 
tional cases may extend below the ileac crest. This enlarge- 
ment is progressive and its development can be watched. 
Superficial, distended veins are often seen. Frequently the 
nodular masses may be plainly felt through the abdominal 
wall and even the umbilicated depressions in the individual 
nodules maybe made out. If the left lobe is involved, the aortic 
impulse is transmitted, differing from the impulse of an aortic 
aneurism chiefly in that it is less expansile. The spleen is rarely 
enlarged. 

As the case progresses, cachexia becomes pronounced. There 
may be considerable annoying itching of the skin. Later, 
bleeding may take place from the skin, nose, stomach and 
bowels. If the latter (Frerich), there is usually intense jaun- 



MORBID GROWTHS. 901 

dice with somnolence and delirium. The face assumes a sallow, 
earth-colored complexion ; emaciation and exhaustion become 
extreme ; and the patient dies of complete breaking-up of the 
whole system, during which, in the secondary form, the symp- 
toms of the primary disease strongly assert themselves. 

Diagnosis. — In the early stage it is almost impossible to 
recognize the affection, and a careful examination into the 
antecedents of the case is important. Waxy liver has both in- 
crease in size and cachexia, but the enlargement is smooth, 
uniform, painless, slow of growth; there is splenic enlarge- 
ment, albuminous urine, often a history of syphilis ; or there 
may be tedious suppurations, especially of the bone, in some 
part of the body. Fatty liver is easily recognized by the ab- 
sence of symptoms of hepatic disease, save enlargement, and 
by its close relationship to alcoholism, consumption, etc. 
Syphilitic liver may closely resemble malignant disease, but 
evidence of syphilitic disease can usually be obtained in the age 
and history of the patient and in the presence of syphilitic 
cicatrizations in the throat. Additionally, jaundice and dropsy 
are hardly ever present; there is rarely tenderness in the 
hepatic region ; the nodules are smaller and softer to the feel, 
and the spleen is often greatly enlarged. Dilatation of the 
gall-bladder gives rise to a large tumor at the lower margin of 
the liver, but this is usually rounded or pear-shaped ; there is 
also intense jaundice, no ascites, often a history of colic, and 
the paroxysms of pain precede, not follow, the other marked 
symptoms. Cancer of the gall-bladder can only be distin- 
guished from cancer of the liver in those rare cases where the 
form and location of the tumor distinctly prove its identity. 
Gall-stones exceptionally resemble hard cancerous nodulated 
swellings, but the tumor is movable and lacks the element of 
continuous growth ; there is a history of gall-stone colic and 
often a sensation of weight rolling from side to side as the 
patient turns in bed. Severe constitutional symptoms, as 
cachexia, are wanting. Cancer of the stomach has severer 
gastric symptoms, as vomiting and pain radiating from the 
stomach; the enlargement rarely involves the hypochondrium, 
and never completely ; the tumor differs in outline. When the 
left lobe of the liver is the seat of cancer, differentiation may be 
practically impossible, save as the hepatic symptoms may 



902 DISEASES OF THE DIGESTIVE ORGANS. 

throw light upon the case. Cancer of the omentum cannot be 
differentiated when the lesser omentum is involved or when a 
loop of the intestine thrust across the enlarged liver gives to it 
the appearance as if the tumor were to the left of and below 
the stomach, as though omental. Usually the boundaries of 
the tumor, the entire absence of jaundice, and the normal con- 
dition of the stools clear up any existing doubt. Hydatid 
tumor of the liver has more or less fluctuation, often quite dis- 
tinct ; no pain ; no serious functional or constitutional disturb- 
ances. 

The course of the disease tends progressively toward a fatal 
termination, which usually takes place within a year, often 
much sooner, from the time the disease was first recognized. 
Death occurs from exhaustion or from some incidental compli- 
cation, as cancerous peritonitis or haemorrhage. 

Treatment is purery palliative and sustaining. Remedies 
like Arsenic, Aurum, Conium, Hydrastis, such as are employed 
in treating cancer in any other part of the body, may be tried 
here ; if not capable of curing, they may prolong life and render 
it less burdensome. Burnett claims to have cured cancer of 
the liver, in two instances, by Cholesterine, 3x. 

Hydatids of the liver will be considered later (see Echinococ- 
cus Disease). 

Simple cysts are rare. If single, they are large ; if multiple, 
they are small and scattered throughout the liver. They con- 
sist of a fibrous wall, lined with pavement epithelium, and con- 
tain a clear fluid. The cysts are not connected with bile ducts 
or vessels. 

Erectile tumors are found at the anterior margin of the liver 
or on the upper surface near the attachment of the suspensory 
ligament. They are of the size of a hazel-nut, red or bluish-red, 
roundish, inclosed in a capsule of delicate connective tissue, 
and contain fluid blood or soft coagula. They rarely project 
beyond the surface of the organ. 

Lymphatic formations are associated with leukaemia. They 
consist of small patches of soft tissue, made up of an aggrega- 
tion of lymphoid cells which are held in meshes of a delicate 
reticulum. Frerichs thinks they are developed from the walls 
of small vessels. 

Tubercles of the liver are associated with acute general 



MALFORMATION AND MALPOSITION. 903 

tuberculosis ; they are miliary, and are found throughout the 
liver, especially on the surface (see article on Tuberculosis). 

Benign growths occur occasionally, but yield no clinical 
signs. 

MALFORMATION AND MALPOSITION. 

Of congenital malformations of the liver, the lobulated liver 
of congenital syphilis is the most important. The so-called 
"corset" liver or "lacing" liver — an acquired malformation — 
is the result of continuously applied severe pressure upon the 
organ, in women resulting from the use of tightly laced corsets 
or waistbands, in men usually from wearing tight belts. The 
deformity consists of a division of the liver into two unequal 
portions by a deep transverse groove or furrow extending the 
entire width of the organ. The peritoneal covering or coating 
of this groove may have become fibroid. The smaller, com- 
pressed portion of the liver is atrophied, dense', fibrinous, and 
is held to the lower portion by a compressed, atrophied, band- 
like structure. The lower and larger portion of the right lobe 
may be freely movable upon the smaller, as though hung upon 
hinges. As seen in practice, no marked symptoms result, but 
the probable eventual occurrence of jaundice or calculi is evi- 
dent. Removal of the pressure, if not too long deferred, with 
rest on the back or side, and the application of heat, may 
restore the parts to their normal shape. Abscesses, cicatriza- 
tions and chronic inflammations affect and alter in varying 
degree the shape of the liver. 

"Movable" liver is due to the relaxation of ligamentous sup- 
port (suspensory and triangular ligaments) of the organ, al- 
lowing the liver to drop down, even entirely below the costal 
margin, as soon as the erect position is assumed. The condi- 
tion is very rare. The liver may be transposed, the right lobe 
occupying the position of the left ; or it may tilt forward, so 
that "the long axis is vertical, not transverse. Instead of the 
edge of the right lobe presenting, just below the costal margin, 
a considerable portion of the surface of the lobe is in contact 
with the abdominal parietes, and the edge may be felt as low, 
perhaps, as the navel. This anteversion is apt to be mistaken 
for enlargement of the organ" (Osier). 



904 DISEASES OF THE DIGESTIVE ORGANS. 



DISEASES OF THE GALL-DUCTS AND GALL- 
BLADDER. 

CATARRHAL JAU1VDICE. 

Jaundice is a symptom, consisting of a yellow discoloration 
of the skin and many of the tissues and fluids of the body. It 
results from the absorption of bile through the lymphatics of 
the liver when the outflow of bile has become obstructed. In 
the present case this obstruction is due to a catarrhal condi- 
tion of the terminal portion of the common duct, with thicken- 
ing of the mucous membrane and occlusion of the duct by a 
plug of inspissated mucus. 

The catarrhal involvement of the affected portion of the 
common duct is in the larger number of instances due to the 
extension to these parts of a gastro-duodenitis, such as often- 
est arises from an error in diet, or from cold or exposure, or as 
may exist in connection with chronic disease of the heart, 
Bright's disease, portal obstruction and malaria. In certain 
infectious fevers, as typhoid fever and pneumonia, catarrhal 
jaundice is common, and on occasions there have been epidem- 
ics of it, in nearly every case as a sequel or concomitant of in- 
fluenza. A passing, but intense, jaundice may result from 
violent emotion. The writer at one time, with several other 
medical men, happened to witness the almost instantaneous 
development of an intense jaundice as the result of violent 
anger. Whether, or not, epidemic and emotional jaundice can 
be properly placed here is an open question. 

Symptoms — The most striking symptom is the yellow color 
of the skin with which all are familiar. A yellow tinting of 
the eye ball is usually noticed first ; the forehead then assumes 
a light yellow color, and gradually the entire body is tinted. 
The color varies from a light, scarcely perceptible yellow to 
intense shades of the same hue, deepening into a dark mahog- 
any ; in the true catarrhal jaundice, however, the intense deep 
coloring is never found. It may be said that the coloring of 
the skin gets darker the more complete the obstruction and 
the lonsrer the duration of the affection. The mucous mem- 



CATARRHAL JAUNDICE. 905 

brane is somewhat jaundiced, as may be seen in the appear- 
ance of the hard and soft palate. The urine contains bile and 
foams "when shaken in a glass. A very satisfactory and easily 
performed test for bile is made by pouring nitric acid into a 
test-tube, adding to it one or two drops of fuming nitric acid. 
A few drops of urine are allowed to flow from a pipette upon 
the side of the glass. An iridescence of green, violet and red 
shows at the point of contact. The fasces become light-colored 
and of soft consistency, like soft clay or putty. The light color 
is due to the absence of bile in the stool ; the soft consistency of 
the stool arises from the presence of undigested or partially 
decomposed fat. The pulse may be normal, oftener slow, 
averaging about forty beats to the minute ; this is presumably 
from the action of the bile salts upon the ganglia of the heart. 
Itching of the skin without any external manifestation of irri- 
tation is an annoying symptom in more than half the cases ; 
its favorite seat is the palm of the hand or the sole of the foot ; 
it is especially troublesome at night, rendering the patient rest- 
less and unable to sleep. Intestinal flatulence is common ; it is 
sometimes associated with colic and constipation. There is 
also gastric uneasiness, with loss of appetite, nausea, empti- 
ness and goneness at the stomach before eating, and a sense of 
great fulness after eating. Dull headache, indifference, mental 
depression and irritability are usually present. The liver gen- 
erally is slightly enlarged, with corresponding increase in the 
area of dulness. 

In some cases the icteric appearance of the eyes is the first 
symptom noticed ; in others, loss of appetite and indigestion, 
with more or less aching in the back and legs and soreness in 
the region of the liver gradually lead up to the jaundice ; when 
gastro-duodenal catarrh is pronounced, dyspepsia may exist 
for a week, or more, before the jaundice sets in. 

In the epidemic form the onset is sudden and the symptoms 
severe ; vomiting may be quite violent ; there is headache, fre- 
quently a chill, followed by moderate fever with a tempera- 
ture of 101° or 102°. 

When the attack is light, recovery takes place within a week, 
or two ; occasionally, however, the case drags along for a 
month, or two, and even longer. The reappearance of bile in 
the stools, with the return of natural color of the faeces, is al- 
ways a sign that recovery is taking place. 



906 DISEASES OF THE DIGESTIVE ORGANS. 

The diagnosis depends upon the appearance of jaundice in 
persons of previously good health, quickly followed by the 
characteristic signs, without great enlargement of the liver or 
the occurrence of ascites, fever, or profound nervous symptoms. 
If the case is very prolonged, the negative results of a carefully 
conducted pln^sical examination and the absence of severe pain 
and pronounced cachexia establish the diagnosis. 

Treatment. — The patient must be kept out-of-doors and be 
made to exercise freely and schematically. The diet should be 
light, consisting chiefly of milk, vegetables and tart fruit, to 
the exclusion of starch, sugar and fat. Milk usually is well 
borne, and may be taken skimmed, with equal parts of Vichy 
or Apollinaris water. Buttermilk generally is relished and 
meets the demands of the case. The chief aim to be secured is 
to avoid "intestinal putricity"; hence, in addition to proper 
diet, the exhibition of inspissated ox-gall, in doses varying 
from 2 to 10 grains at meal time, has been highly recom- 
mended and to some extent appears to supply the existing 
deficienc}- of bile. The kidneys and bowels should be kept 
active, but cathartics must be avoided ; an occasional dessert- 
spoonful of olive oil answers the purpose. One of the most dis- 
tressing symptoms in some cases is intense pruritus. Some re- 
lief from it may be had by the use of hot drinks (hot sage tea) 
or am^ other means which excite sweating (pilocarpine, -^ 
grain, hypodermically). Massage, vapor baths, or sponging 
with a solution of 10 to 20 drops of carbolic acid in a pint of 
water, are each useful. Mercurial washes are advised, but are 
not without danger. 

Various means of promoting the expulsion of the mucous 
plug have been suggested ; of these, the most practical are the 
faradic current (one pole stationary over the region of the gall- 
bladder, the other on the back, at a point opposite the gall- 
bladder, to be moved gently to and fro) and the injection of 
cold water into the rectum, one or two quarts every morning 
before breakfast ; it is claimed that the injection of cold water, 
by reflex action, excites contraction of the gall-bladder and 
favors the expulsion of the plug. 

Therapeutics. — Aconite, in the acute form; from getting 
wet or cold, especially in children. — Arsenic, when there is 
marked gastro-duodenal catarrh; malaria; typhoid fever. — 



CATARRHAL JAUNDICE. 907 

Aurum. In connection with fatty liver. — Berberis. Shooting 
pains in the region of the liver. Morbid hunger alternat- 
ing with loathing of food, or great thirst with aversion 
to drinking; symptoms of gastric catarrh, with heartburn 
and vomiting of food. — Bryonia. An excellent remedy 
when there is gastric catarrh, with swelling and soreness 
of the liver, sharp stitching pains in the liver, with aggrava- 
tion from motion;' thirst; heavy, whitish-yellow coating of 
the tongue. Said to act well after the abuse of calomel or 
when the attack is brought on by a fit of anger. Patient ap- 
pears hot, but complains of feeling cold. — Carduus marianus. 
Dull headache; bitter taste in the mouth; tongue white and 
foul; fulness in the region of the liver. — Chelidonium. Pain 
over the region of the liver ; pain under the right scapula ; in- 
tense itching of the skin. — China. Liver swollen and sensitive 
to touch ; feeling in the right hypochondrium as of ulceration 
beneath the skin. Gastro-duodenal catarrh; tongue yellow; 
oppressive headache at night; loathing of food, yet canine 
hunger. Abdominal distension, with constant desire to belch 
up gas, without relief; fermentation in the bowels. Diarrhoea 
of light, clayish, whitish stools, with emission of fetid flatus. 
From malarial influences, with painful enlargement of the 
spleen. Jaundice of nursing children, with tympanitic abdo- 
men and enlarged liver and spleen. — Digitalis. In cases arising 
from chronic disease of the heart. Enlargement and soreness 
of the liver, as though bruised. Tongue clean or whitish- 
yellow ; bitter or sweetish taste ; vomiting ; stools ash-colored, 
white ; urine high-colored. Action of the heart very slow, some- 
times intermittent.— Hydrastis. Gastro-duodenal catarrh; 
sinking, faintness, goneness at the pit of the stomach. Ten- 
derness in the hepatic region; stools light-colored. — Iodine. 
Jaundice of cirrhotic liver ; after abuse of mercury ; splenic en- 
largement ; great emaciation ; thick coating of the tongue ; 
great thirst ; canine hunger, with vomiting after eating ; diar- 
rhoea of -whitish stools alternating with constipation. — Mer- 
cury. Duodenal catarrh. Flabby, thickly coated tongue, 
showing the indentations of the teeth. Foul odor from the 
mouth. Great hepatic soreness, worse from lying on the right 
side ; severe pains in the liver, worse at night and when lying 
on the right side. Jaundice of new-born children. After the 



908 DISEASES OF THE DIGESTIVE ORGANS. 

abuse of quinine. — Myrica. "Dull, heavy headache in the 
morning; yellow color of the sclerotic and face; tongue yellow; 
very heavy and drowsy; general soreness and aching in the 
muscles; slow pulse; dark, turbid urine" (T. F. Allen). Great 
despondency. — Nux vomica. — Gastro-duodenal catarrh, espe- 
cially of drunkards, with characteristic symptoms. Liver 
swollen, hard, sensitive to pressure. From anger. Faintness, 
followed by great weakness. Wakes about 3 or 4 a. m., then 
falls into a heavy, unrefreshing sleep. Itching of the skin in 
the evening. Impatient, irritable mood. — Phosphorus. Jaun- 
dice depending upon profound amemia or organic disease of the 
liver. Malignant jaundice with sleepiness. — Podophyllum. 
Marked irritation in the duodenum, with fulness and pain in 
the liver and throughout the hepatic region, with intestinal 
and gastric "acid" indigestion. 



CHOLELITHIASIS-GALL-STONES. 

Gall-stones are formed within the liver ducts and are the re- 
sult of precipitation of certain soluble or slightly soluble sub- 
stances which under normal conditions are held in solution by 
the bile. They are composed largely of cholesterine (from 70 to 
80 per cent.), with the addition of coloring matter, bile acids, 
fatty acids and lime salts. The number of stones present in a 
case varies greatly. Sometimes there is but one calculus ; if so, 
the stone is ovoid and large. Oftener there are a number of 
stones, from 5 to 10, or more ; sometimes there are hundreds and 
even thousands. The greater the number, the smaller the size. 
The shape usually is polyhedral, with rounded edges and numer- 
ous facets ; the surface is roughened by erosion or smooth and 
greasy to the "feel." In color they vary from grayish- white to 
an almost black ; usually they are dark-brown, of the color of 
bile pigment. Their consistency is soft, so they crumble 
easily from slight pressure of the fingers ; when composed 
largely of lime, they are very hard. In the liver they are seen 
as large granular masses or in deposits which fill the ducts, 
looking like dark, shiny slate pencils. Structurally they are 
composed of a nucleus, bod3 r , and shell. The nucleus consists of 
lime and coloring matter or hardened mucus ; sometimes it is a 
parasite, rarely some foreign body (needle, fruit-stone). The 



CHOLELITHIASIS— GALL-STONES. 909 

body is made up of cholesterine and coloring matter, amorphous 
or homogeneous, fracturing like soap. The outer shell or crust 
is composed of smooth, horizontal layers of cholesterine. 

Calculi entirely composed of some one substance are rare. 
Those of pure cholesterine are very light, smooth, colorless or 
of grass-green hue, and not often larger than a cherry. Pure 
pigment stones are small and numerous, often of mulberry- 
shape, occasionally contain copper, and are homogeneous 
throughout. Calculi of pure lime are very rare, usually single, 
hard, heavy, of whitish-gray color and uneven on the surface. 

Etiology. — Stone in the gall-bladder may occur at any age, 
but is more frequent in the decline of life. Women, especially 
those who have borne children, suffer from it oftener than men. 
Sedentary habits, with generous living, is held to be an im- 
portant predisposing factor. Any interference "with the out- 
flow of bile, as from tight lacing, may give rise to gall-stones. 
Of the various theories advanced concerning their immediate 
cause, that of precipitation of cholesterine from a catarrhal 
condition of the gall bladder is considered the most rational. 

Symptoms. — Gall-stones may exist for an indefinite period 
without causing disturbance, and, if quite small, may pass 
through the common bile duct and out of the system without 
attracting attention. When a stone of any size passes through 
the ducts, it gives rise to a train of symptoms which are called 
" Biliary colic." This is characterized by intense pain, usually 
appearing two or three hours after eating. It is a radiating 
pain in the right hypochondrium, extending into the shoulder 
and into the right scapula, sometimes into the epigastric 
region, lower chest or arm. Its severity renders it almost 
unendurable and forces from the patient manifestations of 
extreme suffering. It is often accompanied with a chill, fol- 
lowed by fever with a temperature of 102° to 103°. In other 
cases there is slight, if any, fever, but there is vomiting, 
copious sweating and low pulse. 

The liver is frequently enlarged and may be felt below the 
edge of the ribs ; it is tender and sensitive to pressure, espe- 
cially in the region of the gall-bladder, which may be enlarged 
and appear like a pear-shaped mass. Jaundice is noted in 
about half the cases, its intensity depending upon the degree of 
obstruction. It never appears at the beginning of an attack. 



910 DISEASES OF THE DIGESTIVE ORGANS. 

When there is occlusion of the common duct it develops rap- 
idly and may be complete in twelve hours. 

The duration of an attack varies from a few hours to days, 
and even weeks, the pain ceasing when the stone comes to rest, 
and recurring as soon as it again begins to move. Having 
passed into the duodenum, or possibly having dropped back 
into the gall-bladder, relief is at once experienced. » 

The severity of the pain is such that fainting and serious dis- 
turbance of the heart's action is not uncommon, and in very 
nervous persons even convulsions may occur. Rupture of the 
duct, with resulting fatal peritonitis, is among the possibilities. 

Diagnosis of Biliary Colic. — The chief diagnostic points are: 
age and sex; intensity of the pain; locality (right hypochon- 
driac and upper abdominal region); histo^ of previous at- 
tacks ; jaundice. The detection of gall-stones is, of course, 
highl} r important; to accomplish this, the stools must be 
thoroughly mixed with water and then carefully passed 
through a fine sieve. Colic from other causes may resemble 
biliary colic, but the above points almost always render the 
differentiation easy. Gastralgia is a disease of younger people ; 
there are symptoms expressive of a neurosis ; the pain is in the 
epigastric region ; the intervals between the paroxysms are 
much shorter. Ulcer of the stomach has intense pain, but it is 
rather circumscribed, is more continuous, is usually brought 
on by eating, and there is hyperacidity of the gastric juice. 
Lead-colic has a history of lead-poisoning ; there is no jaun- 
dice ; blue lines along the gums are generally seen ; the breath 
is very fetid ; serious nervous disorders, such as palsy, enceph- 
alopathies, etc., are present. 

Certain changes result from chronic obstruction of the ducts 
by gall-stones. If the obstruction is in the cystic duct, the 
gall-bladder is liable to suffer severely. Dilatation of the gall- 
bladder (hydrops vesica? felleae) may occur, resulting in a 
gourd-like and often enormous enlargement of the viscus, pro- 
jecting downward toward the middle line, often as low as the 
navel, and easily recognized. Even when the enlargement is 
moderate it can usually be made out below the edge of the 
liver. The contents of the tumor consist of a thin mucoid fluid, 
at first tinged with bile ; later all traces of bile disappear, and 
the fluid becomes clear, of alkaline reaction or neutral. Sup- 



CHOLELITHIASIS— GALL-STONES. 911 

purative cholecystitis (empyema of the gall-bladder) is rare, 
save as it occurs in connection with cholelithiasis. The dilata- 
tion is great, and pus may be found in very large quantities. 
The tendency is to perforation and abscess-formation. Atrophy 
of the gall-bladder often follows hydrops. The bladder con- 
tracts firmly upon the calculus, forming a closely fitting 
envelope. Sometimes it appears as a small fibrous mass no 
larger than a hazelnut, and even as a tough fibrous string. 
Calcification may follow empyema, and consists of a true infil- 
tration of the walls of the cyst with lime (ossification) or of 
an incrustation of the mucous membrane with salts of lime. 
Acute phlegmonous cystitis and diverticula are rare. 

Obstruction of the common duct may cause dilatation and 
catarrhal or suppurative inflammation of the bile ducts ( cho- 
langitis). The former is characterized by chill, fever and 
sweat, like ague, and jaundice which increases with every 
paroxysm ; this condition may continue for years. "The parox- 
ysms are sharp ; the chill is severe and the temperature may 
reach 104° and 105°. In some cases there is pain and gastric 
irritation (nausea and vomiting); general health declines. The 
liver is usually moderately enlarged. Suppurative cholangeitis 
has fever of a remittent, sometimes intermittent, type, with 
brief apyrexia and moderate jaundice; the latter lacks the 
aggravations of the catarrhal form. The liver is enlarged and 
tender, and signs of septicaemia are present. The suppurative 
process may involve the ducts throughout the liver and also 
the gall-bladder ; or it may extend beyond, resulting in localized 
abscess of the liver, or it may perforate the gall-bladder and 
form an abscess between the liver and stomach. The affection 
proceeds rapidly toward a fatal termination. 

The remote effects of gall-stone are important. The stones 
must either remain in the gall-bladder, or stay fixed in the 
ducts — causing occlusion — or they must find their way out. 
The first is often the case. The effects of occlusion have been 
considered. If the escape of the stone has not been accom- 
plished during biliary colic, nature may attempt to secure the 
same end by ulceration and the formation of a biliary fistula. 
These fistulas usually open into the intestinal canal, preferably 
into the duodenum, either from the common duct or the gall- 
bladder ; less often into the jejunum or ileum, and rarely into 



912 DISEASES OF THE DIGESTIVE ORGANS. 

the colon. Fistulous openings into the stomach are rare. Gall- 
stones have also been discharged into the bladder, the pelvis of 
the kidne}^, through the abdominal wall, or into the peritoneal 
cavity, in which case the escape of the stone is followed occa- 
sionally by the contents of the gall-bladder, resulting in fatal 
peritonitis ; fistulous openings are sometimes found into the 
portal vein or into some cavity in the liver. In some cases a 
very large number of gall-stones may be discharged en masse 
into the intestinal canal, and may there give rise to obstruc- 
tion, especially in the ileum. Of 295 cases of obstruction of the 
bowels, covering a period of eight years, anafyzed by Fitz, 
twenty-three were caused by gall-stones. 

Treatment. — The treatment of an attack of biliar}^ colic con- 
sists almost wholly of measures to subdue pain. The adminis- 
tration of remedies indicated by the totality of s^^mptoms is 
useless so far as prompt relief from intense suffering is con- 
cerned. 

Moist heat, in the form of flannels wrung out of boiling water, 
applied to the upper abdomen and covered with dry cloths, 
with drinks of hot water and a hot bath, should be administered 
at once. If necessary, morphia (\ grain) and atrophia (y^ of 
a grain) may be given hypodermically, and repeated in lighter 
doses as necessary, taking especial pains not to overstep the 
limitations of prudence. Chlorodyne, in 15-drop doses, is often 
useful. Chloroform has proved very comforting when used in- 
telligently. From 15 to 20 drops should be administered by 
means of a napkin or handkerchief during the paroxysm, never 
allowing the patient to become unconscious. 

The paroxysm having ceased, measures must be adopted to 
prevent the continued formation of gall-stones and, if possible, 
to insure the expulsion of any still present. To accomplish the 
former, the patient should be encouraged to exercise freely and 
regularly in the open air ; horse-back riding is especially useful. 
The diet should be light and nourishing, excluding starch and 
sugar. The free use of alkaline mineral waters, as Carlsbad, is 
highly recommended. Or a teaspoonful of Carlsbad salts, dis- 
solved in hot water, may be drunk just before breakfast, 
taking two or three smaller doses, from 10 to 15 grains, dur- 
ing the day. These act upon the bile, preventing its concentra- 
tion, and thus lessen the tendency to the formation of gall- 
stones. 



CHOLELITHIASIS— GALL-STONES. 913 

The olive oil treatment has warm friends and bitter oppo- 
nents. Eminent clinicians have indorsed and condemned it, but 
the "weight of evidence is in its favor. A small teacupful of 
olive oil should be taken in the evening, repeated two or three 
times, on successive days. Glycerine is highly extolled by the 
French school, and for the abortion of an attack is exhibited in 
doses of five drachms to an ounce, repeated for several days, if 
necessary. During the attacks it may be given every morning 
in doses of from one to three teaspoonfuls in half a glass of 
some alkaline water. 

All attempts to find chemical solvents to act upon the gall- 
stone within the body have proved futile. The proposed ex- 
pression of the calculus from the gall bladder by digital manip- 
ulation is both useless and dangerous. 

Exploratory puncture has been practised in extensive disten- 
sion from occlusion of the cystic duct. When all other means 
have failed, and the condition of the patient demands heroic 
measures, the case may have to be referred to the surgeon for 
such relief as the operations of cholecystotomy or cholecystec- 
tomy may offer. 

Remedies recommended for the treatment of the acute par- 
oxysms of biliary colic are Nux vomica, Belladonna, China, 
Chelidonium and Berberis. 

In the treatment of the diathesis itself Chelidonium has 
made a good record. The testimony of Rademacher, who first 
recommended it, has been verified by many others. The remedy 
should be given in light doses of the mother tincture, made 
from the fresh plant, three or four times daily. — Burnett speaks 
highly of Thlaspi. He attributes to it the power of dissolving 
.the calculi, probably by promoting the free secretion of thin 
bile. I have had no experience with it. — China has long been a 
favorite remedy with many. The late Dr. David Thayer at- 
tributed to it great efficacy, maintaining that it cured every 
case of gall-stone colic when taken in the 6th attenuation, 
twice daily, for some length of time. — Euonymin, three or four 
doses daily of the lx trituration, is recommended by Hale 
when there is stupid (occipital) headache, the urine being 
loaded with uric acid. — Calcarea carbonica, when its consti- 
tutional indications are present, has yielded good results and, 
according to Hughes, even controls the acute colic so as to 
render chloroform unnecessary. 
58 



914 DISEASES OF THE DIGESTIVE ORGANS. 

It seems evident that permanent relief is most likely to come 
from remedies which increase the flow of thin bile ; to these be- 
long Podophyllum, Iris, Juglans, Hydrastis, Berberis. 
These, and others mentioned under "Jaundice," should be care- 
fully studied. 

MISCELLANEOUS AFFECTIONS OE THE BIEE 

DUCTS. 

Cancer of the gall-ducts cannot be positively recognized dur- 
ing life. It is characterized by rapidly progressing jaundice, 
with complete absence of bile from the intestine, and without 
attacks of biliary colic. It causes stenosis and dilatation of 
the common duct, and, according to Naunyn, is present in 
about half the cases of chronic jaundice. It is fatal, from 
choljemia, in the course of three or four months. 

Cancer of the gall-bladder is usually secondary. It often 
starts near the fundus or cystic duct and gradually involves 
the wall of the entire bladder, which becomes thickened and 
hardened from the cancerous infiltration, with considerable en- 
largement of the bladder, varying from the size of a fist to a 
child's head. Extension into the liver or the capsule of Glisson 
is common. The symptoms closely resemble those of choleli- 
thiasis, with jaundice in the late stage and strongly marked 
cancerous cachexia. It is rare among young persons. The di- 
agnosis is difficult, for it closely resembles cancer of the pylorus 
and cancer of the liver. An appreciable enlargement of the gall- 
bladder is essential to the diagnosis. The course is rapid and 
the termination fatal. 

In very many cases of prima^ cancer of the duct and gall- 
bladder there is a history of gall-stone ; hence the relative fre- 
quency of the affection in persons beyond middle life and the 
preference for women. Musser collected 118 cases, of which 
the gall-bladder was affected in 100, the ducts in 18, cases. 

Obstruction is usually the result of pressure from without, as 
from cancer of the pancreas or pylorus, involvement of the 
lymph glands of the liver, pressure from abdominal tumors or, 
rarely, from aneurism of the aorta or of some branch of the 
cceliac axis. Foreign bodies, round worms, liver flukes, echi- 
nococci and gall-stones cause obstruction by pressure from 
within. 



DISEASES OF THE BLOOD-VESSELS OF THE LIVER. 915 

Complete occlusion or stenosis results when the size of the 
obstructing body is sufficient to completely fill the duct or as 
the result of ulceration and cicatrization. The symptoms are 
those of chronic obstructive jaundice, with primary enlarge- 
ment and secondary atrophy of the liver, often accompanied 
with hepatic intermittent fever, especially in case of occlusion 
from gall-stones. Permanent occlusion is necessarily fatal. 



DISEASES OF THE BLOOD-YESSELS OE THE 
LIVER. 

Ansemia occurs in connection with fatty or amyloid disease 
of the liver. It affords no characteristic symptoms and is not 
recognized during life. 

Hyperaemia is characterized by uniform enlargement of the 
liver without alteration in the shape of the gland, with sense 
of fulness and distension in the hepatic and gastric region. 
Active hyperaemia results from overeating, from exposure to 
the heat of tropical countries, favored by imprudent habits, 
especially drinking, or from chilling after exposure to heat. It 
is also a feature of malarial poisoning, and may occur in con- 
nection with suppressed menstruation, particularly in women 
near the climacteric. It may result from contusions or wounds 
of the liver. Passive hypersemia is common, and is due chiefly 
to mechanical obstruction to the outflow of blood from the 
liver (see article on Congestion of the Liver); it is also, less 
often, an expression of malaria or a feature of some infectious 
diseases. 

There is congestion of the hepatic vessels and deposition of 
bile pigment in the adjacent hepatic cells, giving to these parts 
a dark coloring; this is strongly contrasted by the light ap- 
pearance of the interlobular veins ; thus, upon section, there is 
produced that semblance to a cut nutmeg which has led to the 
use of the term "nutmeg-liver." The continued distension of 
the hepatic vessels eventually causes atrophy of the liver cells, 
increase of the connective tissue, enlargement and hardness of 
the liver, and finally, in some cases, contraction of the gland. 

The symptoms produced are enlargement of the liver, hard- 
ness, tenderness on pressure, and a vaguely distressing sense of 
fulness and distension in the hepatic region, especially when 



916 DISEASES OF THE DIGESTIVE ORGANS. 

lying on the left side. The tongue is furred, digestion deranged, 
there is bilious vomiting and bilious diarrhoea, sallowness of 
complexion and, at times, moderate jaundice. Bile is often 
thrown freely into the intestine, and then causes griping and 
acrid, smarting evacuations. Headache, irritability of temper 
and general weariness and dulness are often present, with, in 
severe cases, irregularit} r of the heart's action. 

When Iryperasmia is the result of long exposure to malarial 
influences or to a tropical climate, chronic enlargement may 
develop, with, sometimes, structural changes. There will then 
be sallowness of complexion, weakness of circulation, with 
remarkable sensitiveness to changes of temperature, chilliness, 
irritability, lassitude, depression, headache and dizziness. The 
skin becomes dry; the bowels irregular, either stubbornly con- 
stipated or loose ; the urine is loaded with urea and bile. In- 
digestion is usually pronounced. 

Acute congestion general^ disappears with the correction of 
its causes and under proper symptomatic treatment. In very 
stubborn cases depletion of the portal system by salts has 
proved useful. In extreme cases, such as are seen in the tropics, 
the withdrawal of a considerable amount of blood from the 
liver, by means of the aspirator, is successfully practiced. 

Thrombosis of the portal veins occurs in cirrhosis, from ex- 
tension of cancerous diseases generally, from peritoneal inflam- 
mation involving the gastro-hepatic omentum, and from per- 
foration of the vein by gall-stones. Nature obtains relief by 
the establishment of collateral circulation, and the vein then 
may eventually be represented by only a fibrous cord (pyle- 
phlebitis adhesiva). 

Suppurative pylephlebitis is a suppurative inflammation of 
the portal vein and its branches which may involve the entire 
portal system within the liver and may even extend from the 
main branch into the mesenteric and gastric veins. The liver 
is usually enlarged, with normal surface. In some cases little 
pus-pockets are found beneath the capsule ; these communicate 
with the portal vein and represent its distended suppurating 
branches. The pus may be laudable or fetid and stained with 
bile. 

Diseases of the hepatic artery and hepatic vein are rare and 
difficult of recognition. In the former, dilatation, sclerosis and 



DISEASES OF THE PANCREAS. 917 

aneurism have been seen; in the latter, dilatation in connec- 
tion with chronic enlargement of the right heart, embolism, 
and very rarely stenosis of the orifices. 



DISEASES OP THE PANCREAS. 



So far, positive knowledge of the diseases of the pancreas is 
exceedingly limited ; their causation and symptomatology are 
vague, and their recognition during life is more often a matter 
of conjecture, based upon a process of "exclusion, "than a clear- 
cut, positive diagnosis. The following symptoms point to the 
possibility of existing pancreatic diseases : the presence of fat 
in the stools ; the presence of fat in the urine (lipuria); polyuria. 
These symptoms, however, are only suggestive, since each may 
occur in morbid conditions elsewhere, the pancreas being 
healthy. 

Pancreatic Haemorrhage occurs, usually, in males of more 
than forty years of age. Nothing positive is known concern- 
ing its aetiology. The entire gland or portions of it may be in- 
filtrated; the haemorrhage may involve the adjacent subper- 
itoneal tissue, invading even the fatty tissues of the omentum 
and mesentery and that surrounding the kidney. Fatty de- 
generation in connection with haemorrhage is frequent. The 
gland may be normal as to size and structure ; in some cases 
there is slight enlargement ; in others a granular state of the 
epithelium is found. 

The symptoms are vague. Pain may be so slight as to be 
scarcely noticeable or it may be intense. It involves the epi- 
'gastric or lower thoracic region or the abdomen. There may 
be nausea and vomiting and diarrhoea or constipation. Col- 
lapse and death, due "to shock through the solar plexus" 
(Zenker), may occur within a few hours. 

That pancreatic haemorrhage may take place without being 
recognized and without terminating fatally has been demon- 
strated by post-mortem evidence. Haemorrhagic pancreatitis, 
cysts and circumscribed peritonitis of the lesser omental cavity 
are common sequels in non-fatal cases. 



918 DISEASES OF THE DIGESTIVE ORGANS. 

Treatment is limited to measures for the relief of pain and 
stimulants in case of collapse. 

Acute pancreatitis may be hemorrhagic, gangrenous, or sup- 
purative. 

Acute hemorrhagic pancreatitis, as the name suggests, is an 
inflammation of the gland attended with haemorrhage within 
the pancreas. Little is known of its aetiology. It may follow 
pancreatic haemorrhage ; is nearly alway s seen in male adults 
over thirt\ r years of age; is known to have resulted from 
trauma and to occur in persons who have suffered from gastro- 
duodenitis (extension of inflammation along the pancreatic 
duct), and presumably finds a predisposing cause in habits 
which, like chronic alcoholism, give rise to gastric or gastro- 
duodenal catarrh. 

Morbid Anatomy. — The pancreas is enlarged uniformly or at 
one extrem^ — preferably the head — the size of the gland de- 
pending somewhat upon the amount of fatty tissue present. 
Section shows haemorrhagic infiltration limited to the gland, 
chiefly into the interlobular tissue, or involving the peripan- 
creatic structures. The appearance of the gland is red of vary- 
ing shades, more or less mottled from the presence of fat. 
Small, opaque white specks or streaks are abundant and most 
numerous about the lobules ; these are due to the fat-necrosis of 
Balser. This consists of fat-necrosis scattered throughout the 
pancreas, characterized by a peculiar opacity of the fat-tissues, 
which is due to the presence of fat-crystals, either of stearin or 
of fatty acids combined with lime. Various bacteria also are 
present, and experiments have shown that possibly these are 
responsible for the crystallization of the fatty acids. Balser's 
fat-necrosis is highly characteristic of pancreatic disease. Vom- 
iting of bilious, red or blackish matter is common, accompa- 
nied with constipation or, less often, diarrhoea. Tympanitic 
distension of the abdomen is not infrequent. Fever is not 
marked, but delirium is often seen, even early. The tendency 
is to collapse, preceded by hiccough and frightful pain. Osier 
thinks involvement of the cceliac plexus and the stretching of 
the nerves may account for the agonizing pain and the sudden 
collapse. The termination in the great majority of cases is 
fatal within two or three days or a week at the most. The in- 
flammation may assume a gangrenous character. 



DISEASES OF THE PANCREAS. 919 

The diagnosis is uncertain, owing chiefly to the difficulty of 
differentiating from acute perforative peritonitis and intestinal 
obstruction. 

Acute gangrenous pancreatitis is the result of hemorrhagic 
inflammation of the pancreas. 

The symptoms are much the same, with a rather higher tem- 
perature in the gangrenous form, often reaching 103° or 104°. 
There is a tendency to an acute peritonitis which rarely ex- 
tends to the general peritoneal cavity. There may be consider- 
able vomiting, diarrhoea, pain and sometimes haemorrhage. 
Death usually occurs from collapse in from ten to twelve days. 

The appearance of the gland is that of a gangrenous mass, 
dark, slate-colored, and horribly offensive. It may be held in a 
spongy mesh-work of infiltrated tissue or lie almost free in the 
omental cavity, attached to the wall by a few thread-like 
fibres ; or the gland may be found in a large abscess cavity 
forming an appreciable tumor above and to the left of the 
umbilicus ; or it may be discharged through the intestine, in 
which case the patient is liable to recover. The adjacent 
structures are of necessity more or less implicated. 

The diagnosis, according to Fitz, rests chiefly upon the re- 
cognition of a deep-seated peritonitis extending downward 
from the epigastric region. 

The treatment is that of a circumscribed peritonitis, becom- 
ing surgical as soon as the character of the affection is dis- 
tinctly recognized. 

Acute suppurative pancreatitis occurs in those forms of acute 
inflammation of the gland which fail to recover, but escape 
gangrene. Fitz states that there is nothing in the aetiology of 
the original attack "in virtue of which this form of termina- 
tion may be anticipated." 

The pancreas may be studded with a large number of small 
abscesses, which may communicate with each other; again, 
one large abscess may be found, containing creamy pus, the 
contents becoming "cheesy" when the affection has assumed a 
thoroughly chronic form. Involvement of the peripancreatic 
tissues is common. The abscess may discharge into the duo- 
denum or break through the peritonaeum, in the latter case 
giving rise to fibro-purulent peritonitis. Fatty necrosis is rare, 
as compared with other forms of pancreatitis. 



920 DISEASES OF THE DIGESTIVE ORGANS. 

The symptoms are vague and difficult of recognition. Mani- 
festations of inflammation of the gland, as severe pain in the left 
upper abdominal region, vomiting, abdominal distension, etc., 
are present, accompanied with shiverings, chills and irregular 
fever — symptoms, in short, which would indicate the forma- 
tion of pus in any other part of the body. Slight jaundice and 
pain in the hypochondria, with hepatic and splenic enlarge- 
ment, may occur. If the abscess breaks and empties, this is 
commonly preceded by aggravation of the pain and accom- 
panied with temporary- collapse, followed by marked improve- 
ment and recovery. In chronic cases the fever is very slight, 
the skin often is bronzed, the urine may contain sugar, and the 
course of the disease is exceedingly tedious. 

The prognosis is hopeless, death from septicaemia or ascites, 
with extreme debility and emaciation, taking place within a 
period varying from a few weeks to several months or a year, 
according to the acute or chronic character of the case. 

Chronic pancreatitis is exceedingly difficult of recognition. It 
occurs in connection with (congenital) syphilis or diseases of 
the digestive organs, as gastro-duodenal catarrh, or as an inci- 
dental feature of gastric or duodenal ulcer, tumor of the 
stomach, etc. Obstruction of the pancreatic duct, extension of 
a chronic inflammation of the adjacent peritonaeum, or circula- 
tory disturbances in the heart, lungs or liver are among the 
occasional causes of it. 

Anatomically there is an increase of fibrous tissue, causing 
enlargement of the entire gland or of a part of it, oftener the 
head, with increase of its weight. When there is shrinkage of 
the fibrous tissue, lessening of the size of the gland results, a 
condition which oftenest obtains when there is obstruction of 
the ducts. The organ is dense, almost cartilaginous, with 
smooth or granular surface. 

The symptoms are not characteristic. Difficulties of diges- 
tion, as from gastric catarrh, are present in many cases, event- 
ually by their persistence giving rise to much debility and great 
loss of flesh. Diarrhoea is more frequent than constipation, the 
stools being fatty and colorless. There often is epigastric pain 
and tenderness to pressure, varying greatly in degree. Mod- 
erate ascites, slowly progressing enlargement of the spleen 
and glycosuria have each been observed. 



DISEASES OF THE PANCREAS. 921 

The course is tedious and toward a fatal termination in the 
larger number of cases. 

The treatment is symptomatic. Diet should be chiefly fari- 
naceous. The use of minced pancreas or of pancreatin is highly 
recommended. 

Cancer of the pancreas occurs in about six per cent, of all 
cases of cancer. It is a disease of middle life ; more than two- 
thirds of all the cases occur in males. It may be primary or 
secondary, and may involve the entire gland or parts of it ; if 
the latter, preferably the head. The scirrhous form is by far 
the most frequent. Soft varieties, however, are seen ; their 
vascularity may be the occasion of severe and even fatal haem- 
orrhage into the duodenum, stomach or peritoneal cavity. 
Extension of the cancer to adjacent parts is the rule. 

The symptoms are indistinct in the early part of the disease. 
Derangements of appetite and digestion are common ; entire 
loss of appetite is present in some cases, while others suffer 
from ravenous hunger and thirst, with, usually, polyuria. 
Flatulency, heartburn, etc., are frequent. Vomiting becomes a 
common symptom as the disease advances ; the ejected matter 
may contain blood from the ulcerating surface of the tumor. 
Blood may also be present in the stools, which are rather 
frequent and rarely contain fat. Pain is present after the dis- 
ease is well established ; as usual in cancer, it is severe, often 
occurs in paroxysms, and may then closely resemble a neu- 
ralgia involving the lumbar region. Progressive weakness, 
emaciation and eventually a clearly pronounced cancerous 
cachexia are to be expected. The urine, in the later stage, is 
albuminous ; sometimes it contains sugar. 

A tumor may be discovered in about one-half of the cases. 
It is deep-seated and fixed, though later it may become slightly 
movable. It is firm, irregular, roundish. Pressure upon the 
bile ducts gives rise to persistent jaundice. Ascites is caused 
by compression and obliteration of the portal vein. Even 
obstruction of the duodenum from a very large pancreatic 
tumor is possible. 

The course of the disease is usually rapid. Death occurs from 
debility and emaciation or incidentally from intraperitoneal 
haemorrhage or pulmonary embolism, the patient rarely sur- 
viving more than a year. 



922 DISEASES OF THE DIGESTIVE ORGANS. 

The diagnosis rests largely upon the presence of the tumor 
and upon the recognition of muscular fibres in the stools in 
case of a generous meat diet, as well as upon "the absence of 
carbolic acid in the urine when a drachm of salol is taken in 
divided doses during the da}^ " (Fitz). 

When small, the tumor lies behind the stomach and transverse 
colon ; when it is large, it is easily mistaken for cancer of the 
pylorus, duodenum, transverse colon, or liver. The following 
points are to be borne in mind : cancer of the pylorus has dila- 
tation of the stomach, absence of free hydrochloric acid, rarely 
bilious vomiting, and is rather freely movable; cancer of the 
transverse colon has evidence of intestinal obstruction, pres- 
ence of indican in the urine, and can usually be located by in- 
flating the rectum. Duodenal cancer cannot be differentiated. 

The prognosis is unfavorable; the appearance of jaundice 
and ascites means a probably fatal termination within two 
months. 

Pancreatic cysts are due to the impaction of biliary calculi at 
the orifice of the common duct or of pancreatic stones within 
the duct of Wirsung, or to the obliteration of the duct from 
cicatricial contraction. 

The chief symptom is the presence of a tumor in the epigas- 
tric region, usually somewhat to the left of the median line ; it 
ma3% however, project far enough to the right to be mistaken 
for a distended gall-bladder. In exceptional cases the cyst may 
be sufficiently large to fill a considerable part of the anterior 
abdomen, even as far as the brim of the pelvis. "It usually ap- 
pears in the left hypochondrium, between the costal cartilages 
and the median line ; more rarely it is felt in the vicinity of the 
navel. It is globular, resistant, not elastic, smooth, usually 
changing its position somewhat with the movements of the di- 
aphragm, and possessing a slight degree of lateral motion. It 
often transmits the pulsation of the aorta, but has no expan- 
sive pulsation. When deep-seated, it gives no sense of fluctua- 
tion, but as it nears the surface a wave is readily transmitted. 
It is dull on percussion, and on auscultation a sj'stolic souffle 
has been heard, transmitted from the underlying and com- 
pressed aorta." (Fitz.) 

Constitutional symptoms are rarely noticed, even when the 
cvst has attained considerable size. At times there is much 



DISEASES OF THE PANCREAS. 923 

pain, radiating from the vicinity of the ensiform cartilage to 
one side, oftener to the left, sometimes into the left shoulder or 
even into the left side of the face ; the pain may be almost con- 
tinuous or it may occur in severe paroxysms, with symptoms 
threatening collapse. Disturbances of digestion, jaundice, epi- 
gastric fulness and tenderness, irregularity of the bowels, loss 
of flesh and debility exist with varying uniformity and in- 
tensity. When the tumor is very large, embarrassment of 
respiration and oedema are commonly present. 

The duration is exceedingly indefinite, since cases may come 
to a complete "stand-still" for years. Very sudden enlarge- 
ment suggests haemorrhage into the cyst. 

The prognosis must be guarded ; possible interference with 
the circulation and respiration, resulting from a large tumor, 
and danger from rupture, must be borne in mind. 

The diagnosis depends upon the recognition of the tumor. 
"Aspiration results in the escape, under considerable pressure, 
of an alkaline fluid, often more or less blood-stained, which 
usually emulsifies fat, saccharifies starch, more rarely pepton- 
izes albumin." Mistakes are frequent. 

The treatment consists of the establishment of drainage or 
extirpation. 

Pancreatic calculi are connected with chronic inflammation 
and obstruction of the duct. They consist chiefly of carbonate 
of lime, are white or opaque, soft, roundish, sometimes oval, 
and occur singly or in large numbers. Occasionally they are 
elongated, rough and branched, bearing some resemblance to a 
piece of coral. They are commonly associated with dilatation 
of the duct, chronic pancreatitis, abscess, atrophy, and, rarely 
fistula of the gland. 

The symptoms are vague, consisting of disturbances of di- 
gestion which are common to all forms of pancreatic disease. 
However, sharp, radiating pains, starting from the pancreas, 
and not unlike those of biliary colic, at times with jaundice, are 
frequently noticed. Fitz emphasizes the value of progressive, 
sometimes extreme, emaciation and debility, associated with 
fatty stools and glycosuria, with occurrence of paroxysmal 
pains as described. " The latter eventually cease, perhaps to be 
followed by the development of a cystic tumor in the epigas- 
trium. When a calculous pancreatitis is associated with dia- 



924 DISEASES OF THE DIGESTIVE ORGANS. 

betes, excessive appetite and thirst become conspicuous symp- 
toms." 

The duration is indefinite and the prognosis grave. Death 
ma3 r occur suddenly from perforation. 

Therapeutics. — In view of the slight knowledge had of pan- 
creatic disease, the absence of clear-cut symptoms, and the 
rapidly fatal termination of acute inflammation of the gland, 
it cannot be a source of surprise that clinical experience with 
remedies is both limited and unsatisfactory. — Iris versicolor 
has, it is claimed, caused pancreatitis, and it is recommended 
in the treatment of the acute forms on strength of the follow- 
ing S3^mptoms of the drug : burning distress in the region of the 
pancreas ; vomiting of sweetish water ; saliva has a greasy 
taste ; diarrhoea containing undigested fat. — Baryta muriatic a 
has man3 T gastric symptoms which may occur in affections of 
the pancreas, but hardly anything which specifically points to 
special value in this class of disease. Good results, however, 
have been claimed for it by some clinicians. — Iodine is highly 
recommended by Rademacher, Reil, Hughes, and others ; it has 
been given in small doses of the tincture in water. It has many 
striking gastric symptoms, as "canine hunger" and fatty 
diarrhoea, in connection with symptoms which should render 
it important here. — Mercury is considered useful by Reil. — 
Phosphorus, by its close relation to fatty degeneration, gen- 
erally suggests itself. I know of no cure of any disease of the 
pancreas made by it. 

It is more than probable that a closer knowledge of the dis- 
eases under consideration and a proper estimate of the symp- 
toms which characterize them will eventually afford the pro- 
fession opportunit}' for an intelligent selection of remedies. 



DISEASES OF THE PERITONAEUM. 
ACUTE PERITONITIS. 

Acute peritonitis or inflammation of the peritonaeum may be 
primary (idiopathic) or secondary; general (diffuse) or local- 
ized (circumscribed). Idiopathic peritonitis is a rather rare 
affection, and is usually the result of cold or exposure (rheu- 



ACUTE PERITONITIS. 925 

matic peritonitis); nearly all forms of peritoneal inflammation 
are secondary. Localized or circumscribed peritonitis will be 
considered in so far only as it differs from the diffuse form. 

Etiology. — Perforation is by far the most important of all 
the causes. It is an accident which may occur from external 
wounds (including operations), but is oftener seen in ulcera- 
tion of the stomach, intestines, gall-bladder, abscess of the 
liver, spleen or kidneys ; it may also take place in connection 
with the ulceration of typhoid fever, dysentery, appendicitis 
and tuberculosis ; or from a rupture of parametritic abscess 
into the peritonaeum. Extension of inflammatory processes to 
the peritonaeum is common. Here belong the various inflam- 
matory affections, especially the suppurative, of the abdominal 
and pelvic viscera. Septic infection takes place with great ease 
when there is suppurative inflammation, especially of the female 
pelvic organs, as about the ovaries and Fallopian tubes. Per- 
itonitis occurs, more rarely, in small-pox, scarlet fever, measles, 
acute rheumatism, intermittent fever, scurvy, hemorrhagic 
purpura and nephritis. 

Morbid Anatomy. — Injection of the sub-peritoneal blood- 
vessels and minute hemorrhagic effusions occur in the early 
stage. The peritonaeum assumes a clouded aspect and is cov- 
ered, uniformly or in patches, with fibrinous exudation. The 
intestinal coils are distended "with gas ; their walls become 
oedematous and friable, so they tear easily ; adhesions may 
form between them which shortly become remarkably firm. A 
liquid exudation is thrown out early, always in the dependent 
parts, as the pelvis and loins, unless it be confined by adhe- 
sions. The amount of this exudation varies from a few ounces 
to several quarts. It may be fibrinous, sero-fibrinous or puru- 
lent, modified by the peculiar features of each case. Thus, the 
exudation may contain food when there is perforation of the 
stomach ; faeces when the intestine is the seat of a similar acci- 
dent; it may be haemorrhagic (from wounds, ulcerations) or 
putrid (as in cancer). Bacilli are found in large numbers; of 
these the streptococcus pyogenes and the bacillus coli com- 
munis are the most common. 

Circumscribed peritonitis does not differ from the diffuse in 
any essential feature. The inflammatory action and changes 
are rather less intense in degree, and in the purulent form ad- 



926 DISEASES OF THE DIGESTIVE ORGANS. 

hesions are more quickly formed ; this is illustrated in appendi- 
citis and in the pelvic peritonitis occurring in connection with 
puerperal inflammation. 

Symptomatology. — The onset is sudden, consisting of a vio- 
lent chill or of shivering, with intense pain in the abdomen. 
Pain, in nearly all cases, is present from the beginning, and 
throughout constitutes an important and characteristic symp- 
tom. Cases in which there is no pain are practically confined 
to exceptional instances in which the vitality is extremely low 
and the sensorium blunted, as in typhoid fever, and here the 
peritonitis itself may escape detection. The pain frequently 
begins at some particular point, and then is of special value in 
fixing the seat of the perforation, but soon it spreads over the 
entire abdomen ; it usually is most intense just below the um- 
bilicus, but may be felt in other parts at the same time, or may 
be felt only in other parts, as in cases of perforation of the 
stomach, where it is in the chest, back, and shoulders. It is 
intense and often continuous, with sharp paroxysms of exacer- 
bation. It is made worse from the slightest movement; the 
patient instinctively recognizes this by carefully avoiding even 
normally deep breathing and talking. To cough means tor- 
ture. Associated with it is exquisite tenderness of the entire 
abdomen to touch, pressure, or jar. The patient lies on his 
back, with the legs drawn up, often anxiously avoiding even 
the pressure of the bed-covering and manifesting intense suffer- 
ing from any attempt to move him or from touch. Vomiting 
is nearly always an early symptom ; it may be present from 
the very beginning and exist throughout. In some cases there 
is persistent nausea. The vomitus consists first of the contents 
of the stomach; later it becomes bilious, yellow, then green; 
finally the contents of the small intestine are vomited, with 
more or less pronounced fsecal odor. Abdominal distension is 
early, common, and sometimes very great. It is tympanitic in 
character, although in some cases effusion exists. The disten- 
sion, generally speaking, is most pronounced in cases where 
the abdominal walls are thin and yielding, as in the puerperal 
state, and least marked in persons of fine muscular develop- 
ment. Percussion over the distended intestinal coil yields a 
resonant and tympanitic sound ; there is dulness wherever ex- 
tensive effusion exists, hence most pronounced in the depend- 



ACUTE PERITONITIS. 927 

ent parts of the abdomen ; the sign maj , however, be covered 
up by excessive tympanitis. Palpation also reveals the pres- 
ence of liquid. The excessive tenderness of the parts renders it 
difficult to employ these methods, save for diagnostic purposes 
in case of absolute necessity. When the distension is extreme, 
the abdomen protrudes, dome-shaped ; the skin is drawn tense 
and appears shining, and the underlying coils of intestine may 
be plainly seen. In such cases the diaphragm is forced upward, 
with displacement of the heart, lungs and liver, and marked 
changes in the area and extent of hepatic dulness. The gaseous 
distension may yield somewhat after the second day. 

Symptoms of gastro-intestinal irritation are rarely absent. 
Of these, vomiting has already been mentioned. It is often ac- 
companied with frequent eructations, and there may be persist- 
ent and painful hiccough, especially when the upper abdomen 
is the seat of the peritonitis. The tongue at first is moist and 
coated white; later it becomes dry, red, brown and cracked and 
fissured. The bowels are constipated from muscular weakness 
of the intestines or there is diarrhoea, probably due to intesti- 
nal catarrh. Micturition at first is frequent and slightly pain- 
ful ; later, retention from paralysis of the muscular coat of the 
bladder is not uncommon and necessitates the use of the cathe- 
ter. The urine is scanty, high-colored, of high specific gravity, 
acid reaction, and rich in mdican. The temperature of the body 
rises rapidly after the initial chill, reaching perhaps 104° or 
105° ; then it drops, and usually remains below 102° or even 
100° ; in some cases it is subnormal, and, again, just before 
death takes place, it may suddenly rise to 108° or 110°. In the 
main, the elevation is moderate and the fever irregular. The 
pulse is small, hard, wiry, then feeble, almost imperceptible, 
with 110 to 140 beats per minute. Respiration is shallow and 
rapid — thirty or more to the minute— from the pressure exerted 
upon the diaphragm by the tympanitic abdomen and its effects 
upon the lungs and heart ; it is also unfavorably affected by the 
excessive soreness and aggravation of the abdominal pain 
from the respiratory movements. The mind is usually clear 
throughout. 

Effusion of fluids occurs in all but exceptionally severe cases 
with unusually rapid fatal termination. 

Tendency to collapse constitutes one of the most striking pe- 



928 DISEASES OF THE DIGESTIVE ORGANS. 

culiarities of acute diffuse peritonitis. The appearance of the 
patient is such as to forcibly impress itself upon the mind of the 
by-stander. His position is on the back, with legs well drawn 
up. The countenance is haggard, drawn, old, anxious; the 
nose is pinched, the eyes sunken, the temples collapsed, the ears 
cold and prominent, the lips dry, dark, lifeless. The extremities 
are cold, bluish, and the skin of the hands is loose and wrinkled. 
The entire surface of the body looks lead-colored, livid, the 
whole forming a picture of extreme weakness, dumb suffering, 
and of approaching dissolution. 

Localized or circumscribed peritonitis presents a very similar 
group of symptoms, but less intense and modified by peculiar- 
ities of location and the nature of the primary affection, with, 
in the main, far better chances of recovery. Of these, the appen- 
dicular form has been described (see article on Appendicitis). 
Pelvic peritonitis belongs to the domain of gynaecology, and 
only requires mention here. An interesting form of localized 
peritonitis is seen in connection with abscesses sometimes ob- 
served in perforations of the stomach or transverse colon, lying 
between the liver and the diaphragm. The peritonaeum cover- 
ing the liver may be the seat of inflammation, as in cancer or 
abscess of the liver, etc., or from extension of suppuration, tu- 
berculosis, or cancer from the pleura. 

Struempell makes mention of a rare form of circumscribed 
purulent peritonitis which is occasionally seen in children as 
the result of exposure. It declares itself by a painful, fluctuat- 
ing tumor above the left groin, which usually points into the 
rectum and ends by recovery. 

The course of Acute Diffuse Peritonitis is almost always rapid 
and toward a fatal termination, death occurring in particularly 
severe cases in from thirty-six to forty-eight hours, and in three 
to six or, at most, ten days in the less pronounced cases. 
Death is due to complete failure of the vital functions or to 
paralysis of the heart. Among the least hopeful forms is peri- 
tonitis resulting from perforation of the stomach or intestine 
and puerperal septic peritonitis. In very exceptional cases the 
disease may assume a chronic form, the effusion becomes reab- 
sorbed, and the severe symptoms gradually disappear. Even- 
tual complete recovery, however, is rare in such cases, owing 
to the extensive mischief done by the firm inflammatory adhe- 



ACUTE PERITONITIS. 929 

sions and the effect of the inflammation upon the membrane it- 
self. Death here usually results from exhaustion. In other in- 
stances, also exceptional, the inflammation may become limited 
by the peculiar character of the adhesions formed, resulting in 
an abscess which may rupture through the abdominal walls or 
empty itself into the intestine ; such cases usually recover. 

Diagnosis. — The recognition of acute diffuse peritonitis is 
rarely attended with serious difficulty. The suddenness of the 
onset; the vomiting, pain and excessive tenderness in the abdo- 
men, with tympanitis ; moderate fever after the first rise of the 
temperature ; the gravity of the constitutional symptoms, rap- 
idly tending to collapse, are clear and unmistakable. It is 
more difficult, but often important, to determine the primary 
cause of the peritonitis. This is usually found in the history of 
the case (appendicitis, ulcer, etc.) or, as in women, may be ascer- 
tained by careful examination of such organs as might prove 
the starting point of inflammatory action. In the very early 
stage it is possible to mistake various forms of colic (renal, 
biliary, gastro-intestinal, menstrual) for the pain of periton- 
itis, but these forms of colic are almost always associated with 
such local symptoms as will suggest their origin, and generally 
lack the steadiness of the pain, with paroxysmal aggravations 
rather than cessation, which belongs to peritonitis. The dis- 
eases most liable to be mistaken for peritonitis are: acute gas- 
tritis; acute entero-colitis ; puerperal metritis; intestinal ob- 
struction ; hysterical peritonitis ; cystitis with distension of the 
bladder. To these might be added a long list of affections, com- 
monly complicated with peritoneal involvement, which are of 
rare occurrence and difficult of recognition. 

In Acute gastritis the pain and tenderness are centered in the 
epigastric region; vomiting is earlier, more pronounced and 
more stubborn ; the history of the case differs from that of per- 
itonitis. Acute entero-colitis has more distinctly "colicky" 
pains ; the pain is of tener confined to the umbilical region ; oc- 
curs in paroxysms ; nausea and vomiting are more aggressive ; 
tympanitis is not so extensive; diarrhoea is more frequent. 
Puerperal metritis: the symptoms are more localized and, 
even when this fact is not apparent, examination per vaginam 
and rectum reveals exquisite sensitiveness of the uterus to pres- 
sure. Intestinal obstruction is recognized chiefly by the history 
59 



930 DISEASES OF THE DIGESTIVE ORGANS. 

of the case. Hysterical peritonitis occurs in women ; there is 
usually a history of menstrual trouble ; evidence of neurotic 
tendency ; the onset is less violent and threatening ; deep pres- 
sure can generally be borne quite as well as light touch. Cys- 
titis with distension of the bladder may resemble peritonitis 
with retention of urine and strangury. Here the use of the 
catheter promptly relieves the distension ; the urine contains 
mucus and pus, sometimes crystals of phosphates. 

Treatment.— The patient is anxious to remain quiet and in 
the most comfortable position ; it is therefore well to so ar- 
range pillows to the head, back, sides or limbs that he can have 
perfect rest and be spared the necessity of exerting himself. Un- 
wearying attention to this is a source of great comfort to the 
sick. The most urgent symptoms, i. e., pain, vomiting, hic- 
coughing, and the suspension of active peristalsis, are by the 
dominant school met by the exhibition of opium in heavy 
doses, carried to the point of producing toxic symptoms. The 
drug here usually is given by the mouth, in doses of one-half to 
one grain every hour, or one-quarter of a grain subcutaneously, 
until the patient is wholly under its influence. Valid objections 
to such treatment can readily be adduced, but it cannot be de- 
nied that the results obtained are at least no more discourag- 
ing than that had under other methods, and it affords a degree 
of relief from suffering which cannot otherwise be secured. 
The tolerance in peritonitis of very large doses of opium is well 
known. It is evident that care is necessary not to exhibit the 
drug beyond the point of safety. In circumscribed peritonitis 
Struempell voices the opinion of the German school when he 
advocates local bleeding by leeches. 

Hot applications tend to relieve pain, and may be used in the 
form of flax-seed poultices — not too heavy — covered "with oiled 
silk or rubber bags filled with hot water. Cold is well-borne 
by some patients ; if used, it is best to put small pieces of ice in 
a rubber-bag or to mix the ice, finely broken up, with dry 
linseed-meal, making ample provision, by the free use of cotton 
or woolen cloths, to have the water absorbed as quickly as the 
ice melts. Vomiting is not easily controlled. Kuessmaul 
places much reliance upon siphonage ; lumps of ice swallowed 
may give relief. In my own experience a teaspoonful of very 
hot and strong black coffee, given every little while, is often 



CHRONIC PERITONITIS. 931 

satisfactory. Excessive meteorism demands the use of turpen- 
tine externally ; an enema containing a few drops of the oil is 
often useful. Lavage of the stomach, or the long rectal tube, 
introduced as high as possible, and in extreme cases puncturing 
the intestine with a fine trochar, are also advised. Laxatives 
or cathartics for the relief of constipation are to be discounte- 
nanced. Mild saline laxatives, given in hot -water, are recom- 
mended by Tait, Seyfurt, and many others, but this treatment 
has not been generally adopted, save in surgical practice. The 
occasional use of an enema is proper. Stimulants may have to 
be exhibited when collapse threatens. The diet is practically 
restricted to milk, hot or cold, and peptonized, if so desired. 
The patient rarely expresses a wish for food, and it is not well 
to urge him. Rectal feeding is allowable, sometimes necessary. 
Therapeutics will be considered later. 



CHRONIC PERITONITIS. 

Chronic peritonitis is diffuse or localized. With the exception 
of the tubercular form it is a rather rare disease, and usually 
secondary. 

Its aetiology is obscure. In some cases it is a sequel of acute 
peritonitis. When so, there is a history of slow improvement 
of the acute symptoms, with continued sharp, lancinating 
pains in the abdomen, chronic constipation, distension of the 
gall-bladder, repeated attacks of jaundice, tedious absorption 
of the effusion, and the formation of firm fibrinous adhesions in 
various parts of the abdomen; the latter often fix the or- 
gans in an abnormal position and thus give rise to a great 
variety of disturbances of which the first cause is not always 
easily recognized. In other cases the exudation may become 
encapsulated, not rarely leading to the formation of hard con- 
cretions, which in turn may be the starting point of renewed 
inflammatory action or make their exit through the abdominal 
walls or escape into the intestine or bladder. 

Chronic circumscribed peritonitis may exist without being- 
recognized during life. Even in cases where no characteristic 
symptoms existed during life, there have been found extensive 
fibrinous adhesions between abdominal viscera and the adjacent 



932 DISEASES OF THE DIGESTIVE ORGANS. 

peritonaeum. Coils of intestine are firmly glued together; the 
liver may be attached to the diaphragm or abdominal wall; 
the uterus, ovaries and tubes may constitute an almost solid 
mass, firmly adherent to the broad ligament. 

In both forms, the diffused and the circumscribed, the perito- 
naeum itself is materiall}' thickened ; the omentum and mesen- 
tery are often shrunk and disfigured (peritonitis deformans). 

Osier recognizes three forms of chronic peritonitis. Local ad- 
hesive peritonitis, which is most frequent about the spleen, 
"forming adhesions between the capsule and the diaphragm, 
about the liver, less frequently about the intestines and mesen- 
tery." It may give rise to intestinal obstruction by a coil of 
the intestine passing through a loop formed by a fibrous band. 
Diffuse adhesive peritonitis, with intestinal adhesions through- 
out and obliteration of the peritonaeum. Proliferative perito- 
nitis, characterized b} r great thickening of the peritoneal layers, 
sometimes without much adhesion. Here the omentum and 
mesentery show plainly the "rolling up" and "puckering" and 
"shortening" which are a prominent feature of the pathology 
of chronic peritoneal inflammation. The viscera, especially the 
liver and spleen, may be adherent or afford evidence of chronic 
inflammation of the adjacent peritonaeum in the thickness and 
firmness of the surrounding capsule and, often, in the atrophy 
of the organs themselves. 

Tubercular peritonitis is clinically the most important form 
of chronic inflammation of the peritonaeum. This affection is 
still arbitrarily and unnecessarily distinguished from tubercu- 
losis of the peritonaeum. Tuberculosis of the peritonaeum is the 
term applied to an invasion of the peritonaeum by miliary 
tubercles without, or with very little, coincident inflammatory 
changes; it is acute or chronic. In chronic tubercular periton- 
itis the same tubercular deposits are present, and the inflamma- 
tory changes are pronounced, with effusion and often firm and 
extensive adhesions. The disease is secondary; it is an exten- 
sion of tuberculosis from some other part of the body, usually 
the lungs and pleura, or from the intestines, retro-peritoneal 
lymph-glands, spleen, kidneys and female reproductive organs. 
It occurs oftenest between twenty and forty years of age. The 
anatomical changes are chiefly those of a chronic peritonitis. 
The peritonaeum is studded with gray, glistening, translucent 



CHRONIC PERITONITIS. 933 

granules, i. e. tubercles, slightly projecting and of the size of a 
pin-head, which cluster in patches and nodules of grayish- 
white, yellowish, cheesy appearance. The peritonaeum at first 
is injected, and slight effusion of a clear yellowish liquid takes 
place. Later the membrane becomes thickened, ecchymosed, 
often covered with fibrous exudation, and undergoes the vari- 
ous types of adhesion which occur in other forms, producing 
the same effects. Often tubercular masses are found inclosed 
in sacs formed by the adhesion of opposing peritoneal surfaces, 
yielding upon palpation of the abdomen the same sounds which 
are heard in the presence of cancerous or other masses. Thick- 
ening and shortening of the mesentery ; shriveling of the omen- 
tum ; the formation of fistulee ; ulceration and subsequent emp- 
tying into the intestine of the contents of the pouches formed 
by circumscribed adhesions, are all complications liable to 
arise. The exudation is serous or fibrinous, but may contain 
pus and blood. The character of the peritonitis must be deter- 
mined by histological examination of the masses and, if neces- 
sary, by inoculation experiments. 

The condition described as tabes mesenterica belongs here. 

A chronic peritonitis of children is also occasionally seen, oc- 
curring between the age of two and ten years, characterized 
by pallor, languor, some emaciation and moderate ascites 
which disappears in the course of a few months. Recovery is 
the rule. 

The constitutional symptoms of chronic peritonitis are not 
uniformly distinctive. In many cases some inconvenience is felt 
from the abdominal enlargement, but general health remains 
good. In others there is loss of appetite and strength, some 
emaciation, slight and irregular fever, trifling pain in the abdo- 
men, and some tenderness. Physical examination reveals the 
extent of the effusion and the region involved. After absorp- 
tion of the fluid has taken place, with diarrhoea or increased 
flow of urine, it is usually an easy task to outline the periton- 
eal thickening and the tumor-like masses. 

Tubercular peritonitis presents more striking symptoms. 
While the onset may be so gradual that the enlargement itself 
is the first symptom which attracts attention, there is in the 
majority of cases a considerable amount of pain, tenderness 
and fever. The pain and tenderness vary in degree, and may 



934 DISEASES OF THE DIGESTIVE ORGANS. 

be circumscribed or diffuse; they are severe only in exceptional 
cases. The fever is not high, but is much more uniformly pres- 
ent than in the non-tubercular forms. The abdominal enlarge- 
ment, as in other forms of peritonitis, increases and lessens from 
time to time, and differs in different cases. Encapsulation of 
effusion is frequent ; adhesions are common ; all these not only 
affect the external appearance of the abdomen, but give rise to 
digestive disturbances, as loss of appetite, tormenting sense of 
fulness and oppression, diarrhoea, constipation, and even intes- 
tinal obstruction. Eventually the general health fails more and 
more ; the patient wastes with increasing rapidity ; other or- 
gans may be invaded by the tubercular disease, and death 
occurs from general exhaustion, from the effects of tuberculosis 
elsewhere, or from acute peritonitis due to perforation. 

Diagnosis. — The diagnosis of simple chronic peritonitis rests 
largely upon the previous history of the case, the distension of 
the abdominal cavity with fluid, and upon the recognition of 
the structural changes (as thickening of the peritonaeum, ad- 
hesions, etc.) which have been described. Ascites may be ex- 
cluded by the absence of persistent gastro-enteric disease, jaun- 
dice, splenic enlargement, and haemorrhage. Tubercular perit- 
onitis usually occurs in persons who suffer from tuberculous 
affection in other parts of the S} r stem ; the fever is irregular, at 
no time high ; there is no disease of the heart, kidneys or liver ; 
there is progressive emaciation and growing cachexia. 

"In all forms of chronic peritonitis a friction may be felt usu- 
ally in the upper zone of the abdomen" (Osier). 

Prognosis.— In non-tubercular cases the prognosis is favora- 
ble, although the course of the disease often is very tedious and 
recovery may not be complete ; indeed, complete recovery occurs 
only in exceptional cases. The tubercular form presents very little 
hope ; even though the s\'mptoms of peritoneal disease may dis- 
appear, the patient is almost sure to die of general tuberculosis. 
Whether, or not, the performance of laparotomy can materially 
reduce the death list is as yet an unsettled question. 

Treatment.— The treatment consists chiefly of absolute rest 
and a diet of nourishing and easily digested food, with the re- 
lief of such symptoms as may from time to time demand imme- 
diate attention. No excuse can be made for the use of opium 
to relieve pain. Hot fomentations not only control this, but, 



CHRONIC PERITONITIS. 935 

persistently applied for a long time, are credited with a directly 
beneficial action upon the disease. Various inunctions have 
been employed with the view of favoring the absorption of the 
effusion and of scattering the solid masses. Among these are 
solutions of iodine in olive oil (7 to 30 grains of iodine to one 
ounce of oil), mercurial ointment or green soap and water, the 
latter used daily until the skin becomes hard and scaly, taking- 
care to'avoid the navel and hairy parts and to thoroughly 
cover the parts, after the inunction, with oiled silk or a layer 
of thin, soft rubber. Tapping is indicated by extreme disten- 
sion of the abdominal wall. Laparotomy may prove a radical 
cure in the non-tubercular form. 

Therapeutics of Peritonitis.— Aconite. Rheumatic form ; in 
the first stage of all but the perforative form ; in acute exacer- 
bations of chronic peritonitis ; pelvic peritonitis. Characteris- 
tic sthenic fever, with severe, agonizing, burning, cutting, dart- 
ing pain in the bowels, worse from the slightest pressure or 
motion. Fear of death. Urine dark, scanty, hot. Abdomen 
swollen, hot, sensitive to the touch. In the puerperal state ; 
suppression of lochia and milk; red, hot face; dry, hot skin; 
abdominal pain as above. — Apis (see Ascites). Much effusion. 
"Bruised" pain in the abdominal walls, which are very tender. — 
Arsenicum. In cases with rapid and profound exhaustion of 
strength, tendency to collapse, and characteristic constitu- 
tional symptoms. Extreme soreness with burning heat. Drop- 
sical tendency. Persistent sickness at the stomach, with pain- 
ful vomiting. Relief from the use of external heat. Great dis- 
tension of the abdomen. Urine dark, scanty. Metro-periton- 
itis ; small, feeble, intermittent pulse ; low state of the blood. — 
Belladonna. Of first importance. Painful, drum-like disten- 
sion of the abdomen, with much heat and griping, pinching 
pain, often in one spot, worse from the slightest motion ; ex- 
quisite tenderness of the abdomen, so that the slightest touch 
or the pressure of the bed-clothes, or a jar, is unendurable. 
Face flushed or deathly pale, with lustreless eyes. In metro- 
peritonitis and puerperal peritonitis, with the same symptoms, 
clawing pain, sensation as if the contents of the pelvis were 
crowded down and out through the vagina ; urine passed with 
much pain, drop by drop ; f cetor of all the discharges.— Bry- 
onia is especially important at the time when the effusion 



936 DISEASES OF THE DIGESTIVE ORGANS. 

first begins to show itself. There is stitching, lancinating pain 
in the. bowels, worse from motion, accompanied with great 
soreness throughout the abdomen ; considerable fever, with 
thirst; hea\w, white coating of the tongue, which later be- 
comes dry and yellowish-brown ; irritable, anxious, apprehen- 
sive mood ; sleeps badly and dreams about his business affairs. 
Constipation. Involvement of the liver. Catching, stitching 
pain in the diaphragm and chest while breathing. Pehric peri- 
tonitis.— Calcarea carbonica. Useful in tubercular periton- 
itis, especially of children, with characteristic indications, as: 
leucophlegmatic temperament ; "pot-belly;" scrofulous swelling 
of glands ; ravenous hunger with craving for indigestible things 
and very hearty food, like hard-boiled eggs ; indigestion; flatu- 
lency; moderate abdominal dropsy.— Colocynthis. Occasion- 
ally indicated by the characteristic intense "colicky" character 
of the pain, especially when located in the ovarian region. — 
Lachesis is of service in the late stage of cases which have 
safely passed the first, most critical few days, and have then 
assumed a typhoid type. The abdomen is very sensitive, much 
as under Belladonna. The urine is scanty, turbid, with red- 
dish sediment, or very dark, almost blackish. Feels worse 
even- time he awakens from sleep ; feels as though he would 
smother. Extremities cold ; pulse rapid, weak, intermittent. 
Constrictive pain in various parts of the body, especially in the 
orifices. Tongue trembles and catches under the lower teeth. 
Typhlitis. — Mercury (Merc. corr.). Highly useful, not only 
in the earlier stage, with intense burning pain in the abdomen, 
but also when the exudation has become purulent and cachexia 
is well defined. There is shivering and chilliness all the time. 
Cutting, stabbing, griping pains in the abdomen ; copious 
sweating, sticky, hot, cold ; it affords no relief, but adds to his 
discomfort. Complexion pale, sallow, earthy. Mouth feels 
slimy ; tongue flabby and large, not heavily coated ; foul 
breath; swelling, bloating of the feet. Typhlitis. Formation 
of abscesses. — Ranunculus bulbosus. In circumscribed perito- 
nitis, with very severe sharp, stitching pain in the right hypo- 
chondria, with stitches and pressure on top of the shoulder, ar- 
resting breathing. Bruised pain ; sharp pain in the region of 
the liver.— Rhus toxicodendron resembles Lachesis in that it 
acts best in the cases which assume a tj'phoid form. There is 



CANCER OF THE PERITONEUM. 937 

great restlessness ; dry, red tongue, red at the tip ; feeling of a 
heavy weight pressing in the groin ; tendency to foul, slimy 
diarrhoea ; tympanitis ; low, muttering delirium ; pulse irregu- 
lar, weak, intermittent. Metro-peritonitis.— Terebinthina. 
Excessive tympanitis, with dull pain in the region of the 
kidneys, burning in the kidneys, pain extending from the kid- 
neys down the ureters; burning during micturition; strangu- 
ry ; albuminous urine ; urine looks cloudy and smoky. 

Consult also: Arnica when peritonitis results from trauma- 
tism, blow, etc.; low, typhoid state; tympanitis.— Canthari- 
des: burning pain in the sensitive abdomen; great anguish, 
restlessness, pallor ; urinary complications. — Iodine : in tuber- 
cular peritonitis, or in the simple chronic form to hasten the 
absorption of liquids ; scrofulous tendency. Ravenous hunger, 
but seems unable to appropriate what he eats ; chronic hepatic 
disease; jaundice. — Lycopodium : in chronic cases with charac- 
teristic dyspeptic symptoms and great flatulency ; liver-compli- 
cations ; intense pain in the back when the urine begins to flow; 
sand in the urine.— Nux vomica : in tedious or special cases pre- 
senting characteristic gastro-intestinal symptoms.— Opium : 
when there is, or remains after an attack, stubborn constipa- 
tion from paralysis of the intestinal muscular fibre ; sometimes 
useful in acute attacks with marked constipation and the pecu- 
liar sopor of the remedy, with stertorous breathing. — Sul- 
phur in tedious, chronic cases, with slowly progressing re-ab- 
sorption of the effusion and proper constitutional indications.— 
Veratrum aebum : occasionally indicated by intense colic, with 
violent vomiting, coldness of the extremities and symptoms of 
collapse. — Veratrum yiride: highly praised by some reliable 
clinicians when peritonitis occurs in connection with pelvic in- 
flammation. "Dry red strip through the center of the tongue." 
Intense fever and restlessness; rapid, weak pulse; excessive 
pain, tympanitis. 

CANCER OF THE PERITONEUM. 

Cancer of the peritonaeum is rarely primary, but in nearly all 
cases follows upon malignant disease of the stomach, liver, 
retro-peritoneal glands or sexual organs. It is a disease of 
middle life. It is usually of the scirrhous variety, but may be 
encephaloid, colloid or melanotic. The soft forms are more 



938 DISEASES OF THE DIGESTIVE ORGANS. 

often seen in the omentum and may constitute large, even enor- 
mous, growths. Chronic peritonitis, with more or less effusion, 
at times haemorrhagic, is usually present ; occasionally ascites is 
a conspicuous symptom. Pain and tenderness are often pres- 
ent. If the affection assumes the form of cancerous infiltration 
and thickening, friction sounds maj r be heard. Implication of 
adjacent organs is common. Perforation may take place. 

The diagnosis depends upon the physical signs of morbid 
growth; presence of peritonitis and ascites; existence of malig- 
nant disease elsewhere, cachexia, and the result of histological 
examination. The course is chronic, nearly always with pe- 
riods of exacerbation. Haemorrhage may occur, giving rise to 
anaemia and fainting. 

Colloid cancer of the omentum, according to Roberts, pre- 
sents the following signs: Rather irregular enlargement of the 
abdomen ; the umbilicus is stretched, not everted ; palpation re- 
veals the presence of firm, irregular masses; fluctuation, if 
present at all, is very indistinct ; extensive dullness in the ante- 
rior abdominal region ; change of posture produces slight, if 
any, effect upon the physical signs ; presence of a slimy, gelati- 
nous fluid, which may be removed by the aspirator and is oc- 
casionally discharged by the stomach or rectum. 

ASCITES. 

An accumulation of serous fluid in the peritoneal cavity. 

^Etiology. — This condition is in reality a symptom due to 
local or general causes. The former are : chronic (simple, can- 
cerous, tuberculous) inflammation of the peritonaeum ; obstruc- 
tion of the portal vein from any cause; pressure from abdomi- 
nal tumors. The latter are : such chronic diseases of the heart 
(valvular disease) or affections of the lungs (emphysema, 
fibrous pneumonia) as obstruct the passage of blood through 
the heart ; low cachectic states of the system, connected with 
wasting diseases ; hydraemia ; general dropsy (as the dropsy of 
Bright's disease). It is an affection of adult life, but is occa- 
sionally seen in young persons and children, even at birth. 

Morbid Anatomy.— The peritonaeum is normal, perhaps 
somewhat thin in patches, except after tapping, where there 
may be evidence of narrowly circumscribed and moderate in- 



ASCITES. 939 

flammatory action. The exuded fluid is a clear serum of light 
yellow color ; it may be of a greenish tint from the presence of 
biliary coloring matter (cirrhosis of the liver) or reddish or 
brown from the presence of blood pigment (cancer, tuberculo- 
sis). It has a specific gravity of 1.010 or 1.015, which in can- 
cer of the liver may be 1.023. It is alkaline or neutral, con- 
tains albumin (from 3 to 6 per cent.), and may coagulate spon- 
taneously ; large amounts of urea may be present in uraemia. 
Sometimes it is chylous, turbid, milky (chylous ascites) ; in 
cases depending upon cancerous or tubercular disease of the 
peritonaeum it may contain fat-globules (adipose ascites). 

Symptoms. — The symptoms are those arising from the pres- 
sure of the accumulated fluid upon the abdominal organs, con- 
sisting of a sense of fulness, weight and pressure, with crowd- 
ing upward of the liver, lungs and heart. Breathing becomes 
embarrassed ; the patient is unable to lie down and rest. Diges- 
tion is deranged ; there is nausea, easy vomiting, and often con- 
stipation. Urine is passed frequently and in small quantities; 
it is high-colored, albuminous, of high specific gravity. Emaci- 
ation is marked in old cases. 

Inspection shows a protruding abdomen, round and bulging, 
with smooth, shining surface, dry skin, lineae albican tes ; the 
umbilicus is soft, round, protruding, sometimes almost oblit- 
erated. When the patient lies on the back the fluid seeks the 
most dependent part, and there is flattening of the anterior ab- 
domen and bulging in the flanks. When made to stand, the 
bulging is in the front. The veins are distended ; their current 
reversed ; varicosis may arise from thrombosis or portal oblit- 
eration (caput Medusae : dilatation of the veins about the um- 
bilicus from stasis in the portal vein). Palpation by striking 
quickly and sharply upon one side of the abdomen with the fin- 
gers of one hand conveys a wave-like impulse to the other hand 
placed upon the opposite side, most distinct near the top of the 
area of dulness ; this is less distinct if the abdominal walls are 
very thick or the tension is either very great or very slight. 
The edge of an assistant's hand or of a book placed in front of 
the abdomen aids in overcoming the obstruction from a fatty 
or cedematous abdominal wall. Percussion elicits resonance 
over the floating stomach and intestines, which in the dorsal 
position is clearest in the epigastric region, unless the intestinal 



940 DISEASES OF THE DIGESTIVE ORGANS. 

contents are fluid rather than gaseous, or adhesions or shorten- 
ing of the mesentery hold the intestine to the side. The line of 
dulness is usually curved and always shifts to the dependent 
parts. Physical examination is of slight, if any, value unless 
the accumulation is extensive. 

Diagnosis.— A large ovarian cyst may be mistaken for ascites. 
Change of position, however, does not in this case so readily or 
even materially affect the sounds elicited by percussion ; the tu- 
mor more often is unilateral ; the history of the case and exami- 
nation per vaginam and rectum will also afford important 
data. In rare cases a distended bladder may resemble ascites. 
The history of the case, "dribbling" of urine, and the prompt 
relief of the distension from catheterization should solve all 
doubts. 

Treatment. — The use of cathartics, as bitartrate of potash, 
is often followed by a ready disappearance of the dropsy when 
it depends upon renal or cardiac disease. Tapping, however, in 
the larger number of all cases, eventually becomes necessary. 
It is indicated by the amount of distress, especially in breath- 
ing, caused by the accumulated fluid. The operation is compar- 
atively simple and free from danger, and usually is followed by 
immediate temporary relief and by improvement of the nutri- 
tion. In some cases it amounts to a cure of the symptom, no 
reaccumulation of the fluid taking place. In cirrhosis of the 
liver the wisdom of tapping "early and often" is generally rec- 
ognized. It is, however, a safe general rule, amply proved in 
practice, not to tap until the absolute necess^ for doing so is 
obvious. The late Dr. E. U. Jones strongly recommended com- 
pression of the abdomen by means of a wide roller bandage, 
with friction over the abdomen, after the performance of para- 
centesis. 

Therapeutics.— In view of the fact that ascites is a symptom 
which depends upon some other and primary disease, it is seen 
that the true curative remedy takes cognizance of both the pri- 
mary disease and the effusion, and that on this account alone the 
list of possibly indicated remedies must be very large. If, for in- 
stance, the ascites arise from seme disease of the liver or heart, 
all the remedies capable of curatively affecting the liver and the 
heart must be studied, but with particular reference to their 
power of also causing dropsy. On the other hand, such drugs 



ASCITES. 941 

as may, by stimulating the action of the kidneys, bowels or 
skin, carry off a portion of the accumulated fluid, without ref- 
erence to the primary cause of the effusion, may become valu- 
able aids in at least affording temporary help. To the latter 
class belong Apocynum, Pilocarpine (-^ to \ of a grain), Bi- 
tartrate of potassium (10 to 60 grains), Apis, and others ; 
several of these, as Apis, appear to combine the homoeopathic, 
specific and curative action with valuable physiological effects. 
Apium virus should always be used fresh, but especially so in 
ascites ; unless fresh, it will disappoint the prescriber ; it must 
be used low when stimulation of the kidneys is desired. Bruised 
feeling in the abdominal walls, especially upon deep pressure; 
stinging, burning pains ; urine scanty, dark, bloody, loaded 
with casts. Dryness of the skin. Absence of thirst. Great 
difficulty of breathing ; must sit up.— Apocynum cannabinum. 
Stomach irritable, retains nothing ; scanty, muddy urine ; great 
thirst, but drinking causes distress and vomiting. To act di- 
rectly upon the kidneys, it should be given in increasing doses 
of the tincture of the fresh root or of an aqueous infusion, be- 
ginning with at least five-drop doses every three hours, increas- 
ing rapidly until a watery diarrhoea sets in. It is not always 
well-borne, often causing gastric irritation ; yet it is one of the 
most valuable drugs in dropsical conditions.— Arsenicum. In 
cases depending upon disease of the liver, kidneys, heart, and 
in low cachectic states. Its constitutional symptoms must be 
present.— Aurum is less useful here than in merely oedematous 
conditions of the lower limbs. Sometimes, however, its consti- 
tutional symptoms are present and call for its exhibition, espe- 
cially in cardiac and hepatic affections. — China, when there is 
great anaemia, extreme exhaustion of the vital forces from loss 
of blood (purpura haemorrhagica) ; from nursing, or any cause 
that produces exhaustion from loss of fluids. Splenic ascites. 
Malarial poisoning. Roaring in the ears ; cold, clammy skin ; 
indigestion ; voracious hunger, yet rapid emaciation ; charac- 
teristic undigested stool, etc. — Colchicum. Urine scanty, 
bloody, offensive. Skin dry and pale. Gastric derangements. 
He craves things, but cannot eat them when they are brought 
to him ; he is nauseated when he smells the food, especially 
while it is being cooked. Vomiting after trying to eat, followed 
by great weakness.— Digitalis. Hepatic disease. Very scanty 



942 DISEASES OF THE DIGESTIVE ORGANS. 

urine, almost suppressed ; attacks of faintness, seemingly pro- 
ceeding from the heart ; intermitting pulse ; jaundice.— Helle- 
borus. Frequent, but scanty, urination; great thirst; weak, 
small, tremulous pulse ; stools of jelly-like mucus. — Kali car- 
bonicum in complication with affections of the liver and heart, 
with severe, sharp, stitching pains ; flatulent indigestion ; sore- 
ness in the liver from jaundice ; no fever. — Lycopodpum in long- 
standing cases ; malnutrition ; patient thin, emaciated ; in chil- 
dren who are wrinkled and prematurely old. Great despond- 
ency. Atonic dyspepsia, with acid indigestion and trouble- 
some flatulency. Cirrhosis of the liver. Red, sandy sediment 
in the urine. — Mercurtus. Often excellent when the liver is 
affected. Characteristic indications. 

Consult also Bryonia, Hydrastis, Lachesis, Nitric acid, 
Nux vomica, Phosphorus (cirrhosis of the liver), Sulphur (en- 
gorgement of the liver), Squilla. 



PART VII. 

DISEASES OF THE RESPIRATORY 
ORGANS. 



PART VII 



Diseases of the Respiratory Organs. 



DISEASES OF THE NOSE. 



ACUTE NASAL CATARRH. 

Acute nasal catarrh, acute coryza, acute catarrhal rhinitis, is 
a catarrhal inflammation of the nasal mucous membrane, 
usually extending into the sinuses and larynx. Its essential 
cause is probably a micro-organism. The affection is com- 
monly brought on by sudden changes in temperature, chilling, 
getting the feet wet, and exposure to draughts. It is seen in 
the early stage of several acute diseases, as measles, small-pox, 
"la Grippe." 

Symptoms. — Chilliness or shivering, with fulness in the head, 
slight fever, and discharge of a thin, watery character from the 
nose are the first indications of "a cold." There may be aching 
in the back and limbs, with moderate fever, a temperature of, 
usually, about 101°, quick pulse, dry and hot skin, and thirst. 
The nostrils are o.ccluded, necessitating breathing through the 
mouth; the voice is nasal, and the patient complains of severe 
headache, in the forehead, over the eye-brows, when the sinuses 
are involved. Dryness and soreness in the pharynx and laryn- 
geal cough, with huskiness or loss of voice, are not uncommon ; 
extension into the Eustachian tubes gives rise to ear-ache and 
temporary dulness of hearing, and may cause permanent 
trouble in children who take cold often. The conjunctiva may 
be affected, with watery discharge from the eyes. The sense of 
smell is lost for the time being, and that of taste is impaired. 
60 



946 DISEASES OF THE RESPIRATORY ORGANS. 

Labial and nasal herpes are frequent. The nasal discharge, 
after thirty-six or forty-eight hours, becomes thick, yellow, 
greenish, sometimes tinged with blood. It may be copious, pos- 
sibly, but not always, with relief of the tormenting sense of 
nasal occlusion. Sometimes the frontal headache continues, 
but usually improvement begins soon after the nasal discharge 
has become thick ; recovery occurs in a few days, the nasal dis- 
charge and cough disappearing gradually. 

The diagnosis is easy, but the connection of catarrhal symp- 
toms with epidemic influenza and measles must not be over- 
looked. 

The prognosis is always favorable, with the possible excep- 
tion of young infants and very old and feeble people, in whom 
there is danger of pneumonia. 

Treatment.— Although acute coryza in itself is a trifling 
affection and often requires no treatment, its frequent recur- 
rence is highly undesirable, and measures should be taken to 
prevent it. In children a process of "toughening" is advisable, 
if not carried too far. They should be out-of-doors in suitable 
weather, properly clad, but not overdressed. The feet must be 
kept warm and dry ; the shoes heavily soled and the stockings 
of proper material ; the neck must not be too warmly bundled, 
nor overcoats worn save when really necessary. The air of 
close, overheated rooms is highly injurious, and the proper 
ventilation of bed-rooms is of much importance. During an 
attack the patient should remain in-doors, and in bed if it 
is severe. A Turkish bath is often very useful, but must be 
taken with due precaution lest it result in additional cold. The 
bowels should be kept open and a light diet ordered. The in- 
halation of hot water in which hamamelis (Pond's extract) 
has been dissolved frequently relieves the stuffiness. A spray 
of a four-per cent, solution of cocaine is very useful, given three 
or four times, at intervals of a few hours (menthol and 
cocaine, ten grains each, to one ounce of alboline) during the 
early stage of the attack. Cloths wrung out of very hot wa- 
ter applied to the forehead, or steaming the face, is very com- 
forting when there is severe frontal headache from blocking of 
the sinuses ; when these are used, the patient must remain in- 
doors for some little time. Camphor, a drop, or two, on sugar, 
is an old and valuable domestic remedy ; it often breaks up an 
attack. 



CHRONIC NASAL CATARRH. 947 

Therapeutics. — Aconite. In children; from exposure to sud- 
den change of temperature or wind. Chill, fever, sweat, head- 
ache, restlessness, sneezing, dry, hacking cough. — Gelsemium. 
Shivering and chilliness along the back, even during fever; 
headache, general, not localized ; depression ; soreness all over ; 
nasal discharge thin, watery, non-irritating. Epidemic form. — 
Euphrasia. Involvement of the conjunctiva, with sensitive- 
ness to light and acrid lachrymation ; sneezing ; nasal discharge 
non-irritating.— Sambucus. "Snuffles" of infants; jumps up 
during sleep because it cannot breathe ; threatening laryngeal 
involvement ; copious sweating which stops when the child is 
sleeping.— Pulsatilla. After the first stage has passed ; dis- 
charge thick, yellow, greenish; or alternation of fluid and of 
dry coryza; feels better in the open air; no thirst; chilliness. — 
Nux vomica. Coryza fluent during the day, dry at night; 
heavy pain in the forehead, over the eye-brows; shivering. — 
Arsenicum. Especially useful in older people. Copious, wa- 
tery, acrid coryza, irritating the nostrils and eyes. Feels cold 
all the time ; wants heat applied externally ; tearing, asthmatic 
cough. — Arum triphyllum. Coryza with copious, acrid, 
highly irritating discharge ; the nose, in spite of abundant dis- 
charge, seems completely stopped ; nostrils very sore, with con- 
stant desire to bore into the nose and pick it. — Ammonium car- 
bon. Acrid, watery coryza during the day ; at night the nose 
is stopped up. — Allium cepa. Watery, acrid discharge from 
the nose ; bland watery discharge from the eyes. Better in the 
open air. "Splitting" laryngeal cough.— Kali bichrom. Nasal 
discharge tough, stringy. Heavy frontal headache, better 
from pressing upon the bridge of the nose.— Sanguinaria. 
Acrid coryza with much sneezing; soreness and pain in the 
nose ; loss of taste and smell ; headache ; shivering ; sore and 
raw throat ; hacking cough. — Kali iodatum. Copious watery 
discharge from eyes and nose ; yellowish-green discharge from 
the nose. Conjunctival irritation with free lachrymation ; 
stitching pains in the ears ; in scrofulous children. 

CHRONIC NASAL CATARRH. 

This may be simple, hypertrophic, or atrophic. Simple 
chronic rhinitis usually results from repeated attacks of acute 
coryza. The symptoms are similar, rather more unyielding, 



948 DISEASES OF THE RESPIRATORY ORGANS. 

and much aggravated during damp, "bad" weather. There is 
difficulty of breathing through the nose; sneezing; watery, 
later thick and 3'ellowish or blood3', discharge from the nose ; 
frontal headache ; deafness and hoarseness. 

The diagnosis is based upon the presence of these symptoms. 
"The anterior part of the lower turbinals can be pressed back 
with the probe ; there is, too, a decided shrinkage of the tissues 
for a short time after the application of cocaine" (Quay). 

Treatment consists largely of cleansing applications to the 
nasal mucous membrane. This may be accomplished by the use 
of various atomizers or by the post-nasal syringe. After re- 
ceiving treatment the patient must not be allowed to use the 
handkerchief for at least fifteen minutes nor go into the open 
air. If the air condenser is used, it must be kept under low 
pressure. For cleansing, Seller's tablets, Listerine or a solu- 
tion of bicarbonate of soda in water may be employed. The 
use of sulphate of zinc (gr. 1 to water, one ounce), muriate of 
hydrastin (gr. 1 to water, one ounce), boric acid (grs. x to 
water, one ounce), or menthol crystals (grs. x to alboline, one 
ounce) in the form of nasal spray is also beneficial. 

Therapeutics.— Ammon. muriatic, Arsen. iodat., Calcarea 
carbon., Calcarea phosphorica, Allium cepa, Ferrum 
iodat., Hepar, Hydrastis, Kali bichrom., Kali iodat., Mer- 
curius iodat., Natrum arsen., Natrum carbon., Natrum 
muriat., Pulsatilla, Sanguinaria, Sticta, Theridion. For 
special indications see close of chapter. 

Hypertrophic rhinitis is usually a sequel of the simple form. 
Its distinctive pathological features consist of thickening of the 
tissues, swelling of the mucosa of the septum, and enlargement 
of the turbinated bodies, chiefly of the free borders of the mid- 
dle and lower. Hypertrophy of the adenoid tissues in the pha- 
ryngeal vault is often present. The principal symptom pro- 
duced is difficulty of breathing through the nose, with establish- 
ment of "mouth-breathing." There is also impairment of the 
sense of smell and of taste; frontal headache, periodical and of 
a neuralgic character ; hardness of hearing, with tinnitus ; drop- 
ping of mucus into the throat ; lar^mgeal involvement, with 
hoarseness and cough and asthmatic breathing. In children 
mouth-breathing produces a characteristic expression of the 
face, mental dulness, and a noticeable change in the shape of 
the chest. 



CHRONIC NASAL CATARRH. 949 

Treatment is largely surgical, and should be directed by an 
experienced specialist. The indications are: cleansing of the 
parts (bicarbonate of soda, grs. 90; listerine, six drachms; 
water, one ounce), the removal of the growths, and the reduc- 
tion of the hypertrophied mucous membrane. 

Consult Ammon. chlorat., Arsenic, iodat., Ferrum iodat., 
Mercur. sol., Silica. 

Atrophic rhinitis, dry catarrh, fetid catarrh, consists of dry- 
ness of the nasal mucous membrane with atrophy and destruc- 
tion of the glands and follicles. It may result from the hyper- 
trophic form of nasal catarrh, but its aetiology is very uncer- 
tain, save that scrofulous and syphilitic disease is probably 
closely related to it. Ozaena is frequently present in these cases, 
as it may be in other conditions (caries and necrosis of bone, 
foreign bodies, glanders, etc.). It is oftener seen in young per- 
sons, especially those of low vitality and depraved health. 

Pathologically there is atrophy of the epithelium, with de- 
struction of the glands, granulation and necrosis, and forma- 
tion of green, brown, or bloody crusts composed of mucus, pus, 
epithelium, fibrin, serum and mucin, with slight underlying ero- 
sion, but not ulceration, characterized by an intensely offensive 
odor from the nose. The latter constitutes the most distinctive 
symptom of the disease. The sense of smell is impaired and 
soon lost. Nasal respiration is free, but a sense of discomfort 
and dryness in the nose is felt and leads to frequent boring in 
the nose. The scabs are dislodged with difficulty. Epistaxis is 
frequent from attempts to remove the scabs. Implication of 
the pharynx (pharyngitis sicca) is not uncommon. General 
health rarely suffers materially. ''Saddle-back" nose is asso- 
ciated with the affection. 

The prognosis is favorable, though absolute cure exceptional ; 
fixed ozsena may remain. 

Treatment.— Cleanliness is of first importance. Ivins rec- 
ommends the use of a warm solution of salt (10 grains) and 
bicarbonate of soda (10 grains) in water (four ounces) by post- 
nasal syringe or a spray of vaseline or alboline. The scab re- 
moved, the eroded surface must be treated with boric acid, iodol 
or aristol directly applied by insufflation. A 10-per cent, solu- 
tion of menthol in alboline is highly beneficial ; also insufflation 
of the first or second decimal trituration cf permanganate of 



950 DISEASES OF THE RESPIRATORY ORGANS. 

potash. It is said that the applications, to be beneficial* must 
be often changed. The treatment, however, practically belongs 
to the specialist. Remedies likely to prove useful are: Alumina, 
Arsen. iodat., Aurum, Calcar. carbon.. Graphites, Hepar, 
Kali carbonic, Kali bichromicum, Mercurius corros., Ni- 
tric ACID, PSORINUM, PULSATILLA, SEPIA, SlLICA, ThERIDION, 

Thuja. 

Therapeutics of Chronic Nasal Catarrh. — Alumina. Simple 
catarrh of old people;, of elderly women who suffer much from 
leucorrhcea ; chronic constipation. Atrophic form : nose 
swollen, sore; septum ulcerated; discharge greenish, yellow, 
bloody.— Ammonium muriaticum. Clear, acrid, watery nasal 
discharge, corroding the lips ; constant itching in the nose, with 
desire to blow ; hoarseness and burning in the larynx.— Am- 
mon. chlor. Recommended by Ivins when there is hyper- 
trophy, chiefly of the septum.— Arsenicum iodat. Simple form, 
with burning, acrid discharge, predisposition to take cold, and 
asthmatic complications. In the hypertrophic form, with gran- 
ulation of the soft parts, thick yellow discharge, glandular 
swellings. Atrophy, with profuse thick, yellow discharge; 
ozaena in scrofulous subjects.— Aurum. Scrofulous, mercurial, 
syphilitic ozaena. Nasal bones sore, ulcerated ; bones of nose 
and face sore to pressure. Excessive fcetor of the discharges. 
Melancholia. — Calcarea carbonica. Characteristic tempera- 
ment, indigestion, and innutrition. Glandular swellings, espe- 
cially in the neck. Offensive smell in the nose, as from rotten 
eggs. Breathing obstructed only at night. Discharge thick and 
fetid. Ozaena with corroding, foul-looking discharge. Ulcera- 
tion of the septum. Hoarseness.— Calcarea phosphorica. 
Especially useful in anaemic subjects, with adenoid vegetations 
and nasal mucous polypi. Pallor and relaxation of the soft 
parts.— Allium cepa. Useful in chronic cases of simple ca- 
tarrh, with dropping of clear, watery discharge into the throat. 
The nasal obstruction gets worse the moment he enters a 
warm room. — Ferrum iodatum. In anaemic persons, suffering 
from malnutrition ; relaxed and pale mucosa. Adenoid vegeta- 
tions. Follicular pharyngitis. — Graphites. In large persons 
of phlegmatic temperament, with eczematous trouble, espe- 
cially behind the ears, and who take cold easily. Nostrils ul- 
cerated; ozaena. — Hepar. In the simple form. Patient takes 



CHRONIC NASAL CATARRH. 951 

cold easily, from the slightest current of air. In case of sup- 
pressed eruptions. Copious, purulent, stringy discharge. Hard 
swelling of the tonsils and (anterior) cervical glands. In ozaena: 
symptoms like those of Mercury, which Mercury fails to rel- 
ieve. Bones of nose sensitive to pressure or touch. Face of a 
dirty, yellow, unhealthy color. — Hydrastis. Nose raw, sore; air 
feels cold in the nose. Frontal headache. Copious thick, white, 
yellow, tenacious discharge. — Kali bichromicum. More useful 
in the atrophic than in the simple form. Great dryness of the 
nose. Severe pain across the bridge of the nose. Involvement 
of the frontal sinuses and naso-pharynx. Thick, offensive, 
lumpy, ropy discharge, sometimes blood-stained, from the nose 
and throat. — Kali iodatum. In simple catarrh, with attacks 
of chilliness and heat, involvement of the ear, sneezing, acrid 
watery discharge ; the latter sometimes stops, and then there is 
much headache over the eye-brows. In ozaena, with syphilitic 
history, ulceration of the septum, throbbing and burning in the 
nose; thick, greenish-yellow, excoriating discharge; otor- 
rhoea.— Mercurius corrosivus. Ozaena. Acrid discharge 
from the nose, causing burning, smarting pain ; glue-like dis- 
charges, running into the naso-pharynx, and there forming 
scabs.— Mercurius iodatus. Discharges whitish-yellow or 
greenish, fetid or corrosive ; glandular involvement, enlarged 
tonsils. Characteristic constitutional symptoms.— Natrum 
arsen. Burning watery discharge from the eyes, with supra- 
orbital headache. Sensation constantly as trTough the nose 
were stopped up ; pain in the root of the nose.— Natrum car- 
bonicum. Worse from every draught of air ; discharge thick, 
yellow, irritating, excoriating lips and nose. Eczema, acne, 
erythema of the nose ; nose red and sore to touch. — Natrum 
muriaticum. Great sensitiveness to cold or heat; frequent 
sneezing; nose "runs" all the time, especially as soon as he steps 
into the open air. Loss of smell. Fever-blisters about the 
mouth.— Nitric acid. Syphilitic ozaena; after abuse of mer- 
cury. Dryness of nose and throat. Nose bleeds when 
touched.— Psorinum. Acrid, ichorous discharge. Horrible 
foetor.— Pulsatilla. In simple catarrh with abundant heavy 
yellow or greenish, bland discharge, with loss of taste and 
smell, aggravations in the warm room, chilliness, and charac- 
teristic mental symptoms. Also given in ozaena, when the dis- 



952 DISEASES OF THE RESPIRATORY ORGANS. 

charge often changes in color and consistency.— Sanguinaria. 
Simple catarrh, with burning in the nostrils, pain in the root 
of the nose and frontal sinuses ; pain in the temples ; rawness 
of the throat; sharp, hard, dry cough, sometimes almost ccn- 
cussive, and discharge of thin, watery, acrid fluid from the nose. 
— Sepia is highly recommended when there is "yellow or green 
ish crusts or plugs discharged through the anterior nares, and 
a gnawing pain or pressure at the bridge of the nose." — Silica. 
Deep-seated destruction of the parts with painful d^ness or 
copious purulent excoriating discharge ; itching of the tip of 
the nose ; throat dry and painful. Ulceration of deep struct- 
ures. — Sticta pulmonarla. Profuse discharge of bloody pus ; 
distressing cough and oppression of the chest. Dryness of the 
nose and palate ; they feel as stiff as leather, with occasional 
discharge of scabby mucus, worse in the evening and at night. 
Catarrh, with constant blowing of the nose, but no discharge. 
— Theridion. Offensive greenish-yellow discharge ; cases com- 
plicated with bronchial or pulmonary catarrh. Feeling of ful- 
ness or pressure at the bridge of the nose. Crusts form, are 
drawn into the throat, and expectorated. — Thuja. "Nasal ca- 
tarrh, with quantities of thick, green mucus, pus and blood, 
that seem to come from the frontal sinuses. Painful scabs in 
the nostrils. Warts on the nose" (T. F. Allen). 

HAY FEVER. 

Hay fever, autumnal catarrh, pollen catarrh, rose cold, peri- 
odical hyperaesthetic rhinitis, is an affection of the upper air 
passages, with asthmatic tendenc\% which is observed at certain 
seasons of the year, in the eastern and middle states from the 
month of June to the appearance of the first severe frost, which 
puts an end to the trouble. It is seen oftener in males than in 
females, rarely before the tenth year or, as a first attack, later 
than the twenty-fifth year. 

Etiology —The chief factors are : The presence in the air of 
certain substances which irritate the nasal mucous membrane, 
principally the pollen of some plants, which may be carried 
great distances. An irritable condition of the nasal mucous 
membrane ; the cure of a local disease may result in the cure of 
hay-fever. A neurotic temperament; this shows itself in the 



HAY FEYER. 953 

liability to hay -fever from causes which otherwise would prove 
harmless. Heredity plays an important part. Persons of seden- 
tary occupation are said to fall easy victims. It is more com- 
mon in America than in Europe. 

Symptoms.— Weariness and lassitude often precede the at- 
tack. An acute catarrh gradually develops, with paroxysms of 
sneezing, followed by copious watery discharge from the nose, 
congestion of the eyes with abundant secretion of tears, and 
often considerable dryness and smarting in the roof of the 
mouth. These symptoms often are severe and distressing. The 
discharge from eyes and nose is irritating, and the swollen con- 
dition of the mucous membrane of the nose renders breathing 
difficult or even impossible. Headache may be very severe, 
and in some cases there is much shivering and slight, irreg- 
ular fever. The patient soon begins to cough ; there are all the 
symptoms of an acute bronchial catarrh, with paroxysms of 
asthma. The affection has many features which render it very 
unpleasant and trying, and is not readily amenable to treat- 
ment at home; under these circumstances, and in view of 'the 
neurotic element so commonly present, it cannot be a source of 
surprise that its yearly visitations are productive of mental de- 
pression bordering upon despair. 

The diagnosis is not difficult. It is a summer-disease, not 
brought on by conditions of weather which cause catarrh ; nor 
does the discharge after a time assume the thick, semi-purulent 
character which is a feature of catarrh ; the history of its ap- 
pearance and disappearance also is striking. 

Treatment.— This comprises, first of all, the removal of ab- 
normal states of the nasal mucous membrane, including the 
destruction by the galvano-cautery of the so-called " sensitive 
areas" and the reduction of infiltration or hypertrophy of the 
turbinated bodies. Proper attention must be paid to existing 
disturbances of the nervous system. Finally, in addition to 
appropriate medication, the patient should have the benefit of 
a temporary sojourn in some favorable locality during the 
months of danger. 

The United States Hay Fever Association have for many 
years studied the climatic feature of the treatment, without, so 
far, quite solving the problem. It is stated that the inhabit- 
ants of cities of the Atlantic sea-coast and of the central states 



954 DISEASES OF THE RESPIRATORY ORGANS. 

enjoy complete immunity in the Adirondacks and White Moun- 
tains. From personal observation and from intimate knowl- 
edge of a very large number of such cases I believe that Put-in- 
Bay, on the shores of Lake Erie, and Petoske}', Michigan, on 
Little Traverse Bay (Lake Michigan) offer equal advantages. 
Often a sea-voyage answers the purpose, but the offending 
pollen can travel immense distances and may find an unlucky 
victim when least expected. 

Therapeutics. — The remedies under acute and chronic catarrh 
must be carefully studied. The following are especially useful : 
Arsenicum iodat. Much prostration ; tendency to asthma ; 
pallor of the face ; irritating character of the nasal discharges ; 
great sensitiveness of smell; burning dr\mess in the larynx, 
with paroxysmal, suffocating cough, especially at night, with 
asthma (worse after midnight) and scanty expectoration. — 
Allium cepa. Thin, watery, excoriating discharge from the 
nose; congestion of the eyes, with redness of the eye-balls and 
copious bland lachrymation; severe hoarseness; tearing cough, 
with a sensation as if the throat would split to pieces. — 
Euphrasia. S3^mptoms of influenza. Catarrhal irritation of 
the conjunctiva, with free discharge from the eyes ; soreness of 
the lids from the acridity of the discharge. Sneezing, with co- 
pious discharge of bland, watery mucus from the nose. Cough, 
dry and tickling, sometimes with free expectoration, through- 
out the day, but stopping at night.— Gelsemium. Great ex- 
haustion. Feels chilly and feverish, as though malarious. 
Takes cold easily. Characteristic head symptoms. — Naphtha- 
line. Enjoys an extensive reputation and is by many con 
sidered almost a specific. It must be given in the low tritura- 
tions (lx or 2x). Its special indication is the severity of the 
asthma. There is much sneezing; the eyes are inflamed and- 
painful, the head hot, severe spasmodic bronchial cough, with 
asthma ; soreness in the chest and feeling of tightness about 
the stomach, obliging him to loosen his clothing. Better in the 
open air. — Sabadilla. Violent spasmodic sneezing and lach- 
rymation while in the open air ; burning, itching, tingling in 
ths nose ; the nose is swollen, and there is watery discharge 
from it. Hoarseness ; dry short cough at night ; wheezing in 
the trachea when lying down. 



EPISTAXIS. 955 

EPISTAXI§. 

Nose-bleed results from injuries to the nasal mucous mem- 
brane by picking at the nose, from blows or other traumatism. 
It is common in nasal catarrh. It may be an effect of se- 
rious injury to the skull (fractures). It is of frequent occur- 
rence in full-blooded, plethoric young persons, especially about 
the period of adolescence, preceded by fulness of the head and 
flushing of the face. It is also seen in connection with haemo- 
philia, chronic anaemia, and in the early stage of some fevers, 
as typhoid fever. Vicarious nose-bleed occurs in suppressed 
menstruation. The nose-bleed which is a common effect of as- 
cending into a high altitude is in no sense pathological. The 
bleeding may take place from one or both nostrils ; it is caused 
by capillary oozing or diapedes. 

There are no symptoms save the loss of blood, which in ex- 
ceptionally bad cases may give rise to exhaustion and anaemia. 

The diagnosis is easy ; if blood from the posterior nares 
should find its way into the throat and be swallowed, bleeding 
from the lungs or stomach might be suspected. 

Treatment. — Treatment is rarely necessary, the bleeding al- 
most always stopping of its own accord by clotting. Postural 
treatment, by holding the arms above the head, and the injec- 
tion of ice-water or of hot water into the nostril, are usually 
all-sufficient. If the haemorrhage occurs from the lower portion 
of the septum, about half an inch from the nasal opening, firm 
outside pressure will arrest it. Lemon-juice locally applied, 
cob-webs introduced into the nostril, or astringents (tannic 
acid, zinc, alum) applied on a pledget of cotton or injected, are 
efficient common remedies. Tamponing (antipyrine, ergot, 
rarely peroxide of iron) may be necessary when the haemor- 
rhage follows an operation ; if so, the tampon must be firmly 
placed and be allowed to remain at least for twenty-four hours, 
not to be removed until previously softened by a warm injec- 
tion. If from an ulcer, apply chromic acid or cauterize. Tam- 
poning is the last resort in bleeding from the posterior nares 
when other methods fail. "A soft rubber catheter can be util- 
ized. Through the lumen of the catheter a strong string or 
cat-gut (about two feet in length) is passed. When the instru- 
ment is carried through the nostril into the pharynx, the end of 



956 DISEASES OF THE RESPIRATORY ORGANS. 

the string is seized with forceps and brought out of the mouth. 
The tampon is then firmly tied to the middle of the string, and 
the plug pulled up behind the soft palate and into the nostril. 
The two strings are now tied firmly over the upper lip. It is 
always necessary to hold the soft palate forward with the in 
dex finger, so as to permit the tampon to pass behind it. The 
tampon should be removed in from twenty-four to forty-eight 
hours" (Quay). 

When the bleeding depends upon constitutional causes, the 
remedy indicated by the totality of symptoms must be ex- 
hibited. 



DISEASES OF THE LARYNX. 



ACUTE LARYNGITIS. 

^Etiology.— Acute laryngitis occurs as an independent affec- 
tion or in connection with catarrhal inflammation of the naso- 
pharynx or bronchi. It is usually the result of taking cold or 
of "straining" the larynx by unwise or violent use of the voice, 
as talking too loud, shouting, excessive use of the vocal organs 
in public speaking, especially in badly ventilated rooms. Other 
common causes are: irritation of the throat, as from inhaling 
smoke or irritating gases ; direct, local action of corrosive sub- 
stances or very hot liquids ; less frequently, traumatism, as 
from external violence or the presence of a foreign body in the 
throat. The affection is often seen in connection with measles, 
influenza, scarlet fever, typhoid and erj'sipelas. It is most prev- 
alent in the damp, cold months of winter and early spring. 

Symptomatology. — Some cases begin with the symptoms of 
an acute coryza ; in others, annoying dryness of the throat, 
with tickling in the larynx, sensitiveness to inspired cold air, 
and dry harsh cough set in at once. The cough is character- 
istic in that it possesses a dry, hard, metallic quality which is 
readily recognized, and is even by the laity described as "laryn- 
geal." There is at first slight, if any, expectoration; later 
scanty expectoration of glairy mucus takes place, which be- 
comes mueo-purulent and sometimes blood-streaked, but never 



ACUTE LARYNGITIS. 957 

copious. The voice is husky, even early in the course of the 
affection, then becomes hoarse, and may be completely lost ; 
considerable pain is provoked by attempts to use it. There is 
more or less laryngeal tenderness to external pressure and pain 
upon inspiration. Some dyspnoea, depending upon oedema of 
the parts, is not infrequently observed in adults; generally 
speaking dyspnoea is not a conspicuous symptom, save as seen 
in the spasmodic form of children. Slight fever, lassitude and 
headache may be present. If the case is one of unusual sever- 
ity, the cough may be very violent and accompanied with much 
pain, difficult swallowing and pronounced dyspnoea. 

Examination of the parts with the laryngoscope reveals a 
swollen and tumefied laryngeal mucosa, especially about the 
ary-epiglottidean folds, swelling and redness of the vocal cords, 
with infiltration of the adjacent mucosa and muscular struct- 
ures, interfering with the free action of the vocal cords and 
preventing their approximation during phonati on. The parts 
are covered with a thin coating of mucus. Superficial erosions, 
especially on the cords, are seen in severe cases. 

The disease runs a favorable course in a few days to a week 
or ten days. Recovery may be imperfect, resulting in chronic 
laryngitis. 

Diagnosis. — The laryngoscope establishes the diagnosis, 
though the mirror often cannot be used satisfactorily in chil- 
dren. The character of the cough, the alterations in the quality 
of the voice, and the progressive nature of the disease are 
usually sufficient. Exceptional cases will be pointed out here- 
after. 

Treatment.— The patient should be kept in bed. The temper- 
ature of the room should be maintained at 70°, and the atmos- 
phere saturated with moisture. The use of the voice must be 
prohibited ; unavoidable talking must be done in a whisper. 
The external application of ice to the throat (ice bags) is recom- 
mended, but its advantages in the average case seem doubtful. 
Soothing sprays are often very comforting. 

Therapeutics. — Aconite is the most important remedy in the 
beginning, and often all-sufficient. — Belladonna ranks next 
in usefulness, also early. There is considerable arterial excite- 
ment, flushed face, vivid redness of the larynx and throat, con- 
strictive dryness and sensation of dust in the larynx, provoking 



958 DISEASES OF THE RESPIRATORY ORGANS. 

tickling and coughing ; painful swallowing. — Bromine. Cough 
sounds croupy; larynx feels raw and "scraped." In excep- 
tional cases only.— Calcarea iodata. "An admirable remedy 
when there is rawness, burning, soreness and tenderness of the 
larynx, with frequent cough, hoarse and barking, and a sensa- 
tion of tightness and constriction. Dissolve five grains of the 
crude drug in half a glass of water, and give a teaspoonful 
every half hour" (Hale).— Ferrum phosphoricum. Like Aco- 
nite, in the early stage, with practically the same indications 
without its fever, restlessness and anxiety . Highly recommended 
by Ivins, Houghton, and other specialists.— Guaiacum. Burn- 
ing sensation in the larynx ; sticking pain from the larynx to 
the left clavicle ; frequent dry cough, with hacking and hawk- 
ing, and scanty expectoration of mucus. "Rheumatic cases." 
The bands are boggy, and there is loss of tone and lustre. C. 
M. Thomas uses a spray of one drachm of the ammoniated 
tincture to one ounce of water.— Hepar sulph. Hoarseness ; 
deep, harsh voice ; barking, croupy cough ; very sensitive to 
even slight draught. Considerable dyspnoea. Rattling of mu- 
cus in the larynx. In children.— Iodum. Soreness of larynx to 
touch ; cough dry, harsh, croupy ; watery discharge from the 
nose.— Phosphorus. Constant dry, hacking cough, at times 
with much tickling in the throat; the larynx feels sore and 
rough ; cough and laryngeal soreness increased by laughing, 
talking, swallowing, and change from warm to cool air. Ex- 
pectoration scanty, sometimes blood-streaked.— Sanguinaria. 
Soreness, dryness and swelling of the larynx ; dry cough, with 
tickling in the throat-pit and crawling extending beneath the 
sternum. Great dyspnoea, respiration sawing or rasping, 
worse from lying down. Scanty glairy expectoration.— Spon- 
GIA. Shrill, barking, dry croupy cough, sometimes with scanty, 
tenacious expectoration. Dyspnoea. Spasmodic cough. La- 
bored, wheezing inspiration. 

Under the term "Submucous laryngitis" a severe but rare form 
of acute laryngitis is described which involves the deep tissues, 
causing serous or bloody infiltration, with resultant narrow- 
ing of the larynx. The aetiology is that of the common acute 
form, which it also resembles in the symptoms. There is, how- 
ever, a pronounced sense of laryngeal fulness and swelling, 
with more painful deglutition and more annoying dyspnoea. 



ACUTE LARYNGITIS. 959 

Pain is a conspicuous symptom, aggravated by coughing, 
swallowing, talking, breathing and external pressure. There is 
often considerable fever, with a temperature of 102° to 104° 
F. The respiratory embarrassment may become extreme, and 
death may result from suffocation or blood deterioration. 

The diagnosis can only be made positively by the use of the 
mirror. 

The prognosis is grave, some cases proving fatal within 
twenty-four hours. 

The treatment consists of rest in bed, absolute interdiction of 
the use of the voice, inhalation of moist air (steam), and the 
employment of menthol, eucalyptol or lime-water spray. Tan- 
nic acid, in steam, may aid in reducing the infiltration. A four 
per cent, cocaine spray and heat applied externally often relieve 
the pain. Scarification, intubation or tracheotomy may be- 
come necessary. The remedies most serviceable are: Apis, Aco- 
nite, Belladonna (see cedematous laryngitis). 

Laryngitis Stridulus, spasmodic or false croup, is an acute 
laryngitis which occurs in children, usually during the period 
of first dentition, oftenest in the second and third year of life, 
not usually after the fifth year. In rare cases it is seen up to 
the age of adolescence and, very exceptionally, even in adult life. 
The distinctive feature of this type consists of paroxysms of 
difficult inspiration, with a sense of impending suffocation, 
commonly occurring in the middle of the night. The child has 
the symptoms of a moderate laryngitis, with the usual indis- 
position and occasionally dry, metallic cough, possibly slight 
fever, but retires and goes to sleep feeling fairly well'. In the 
night, oftenest about midnight, the patient suddenly and 
with a start awakens from sound sleep, unable to "get his 
breath." The inspiratory effort is prolonged and intense, ac- 
companied with a shrill stridulous sound. The appearance and 
actions of the child manifest the distressing sense of impending 
suffocation. The face is distorted, expressing terror; the 
pulse is rapid and small; the upper chest is violently drawn in 
from the great muscular effort made, causing a marked reces- 
sion in the supra-sternal and supra-clavicular spaces ; the voice 
is hoarse, and the frequent cough sounds harsh, metallic, 
"croupy;" the lips and tips of the fingers often become cyan- 
otic. The paroxysm having passed off, the child will probably 



960 DISEASES OF THE RESPIRATORY ORGANS. 

fall asleep and rest until morning, but occasionally recurrences 
take place. This usually is repeated on the second, rarely the 
third, night, the intervening days being passed quietly enough, 
except that there is harsh cough and other symptoms of laryn- 
gitis. 

The peculiar tendency on part of children to this striking 
manifestation depends largely upon the narrowness of the 
lar}mx of childhood, which is seriously accentuated by even 
moderate swelling of the mucous membrane, upon the accumu- 
lation of mucous secretion, and reflex spasm of the glottis. It 
is not, in the present case, of purely nervous origin. No special 
anatomical features, save those of simple catarrh, have been 
observed. 

The diagnosis, in spite of the pronounced character of the 
symptoms, is not always easy, since laryngismus stridulus 
and membranous laryngitis present a close similarity. Laryn- 
gismus stridulus, however, has no history of catarrhal involve- 
ment, no hoarseness or aphonia, and very slight fever ; the at- 
tacks do not come on at night, and they pass off with a pro- 
longed crowing respiration. Pseudo-membranous croup not 
only has much more profound constitutional disturbances, but 
often exudation on the tonsils and adjacent parts, with enlarge- 
ment of the cervical glands. The course of the disease differs 
in that it is continuous and lacks the nightly occurrence of the 
paroxysms, the freedom from annoyance during the day, and 
the probable cessation of the seizures after the third night. 

Treatment.— The arrest of the paroxysms is the first care. 
To this end a hot bath or the immediate application to the 
throat of a sponge dipped in hot water is highly useful. An 
emetic (zinc or ipecacuanha) promptly administered answers the 
same purpose. Wrapping the throat in a piece of flannel dipped 
in kerosene is a common domestic remedy of efficiency. If nec- 
essary, a few whiffs of chloroform may be inhaled. The physi- 
cian should assure the mother, especially if young and inex- 
perienced, of the entire absence of danger. 

Therapeutics.— Aconite and Spongia, given in the low atten- 
uations and at frequent intervals, almost always quickly con- 
trol the paroxysms. After this has been accomplished, the 
further exhibition of the indicated remedy (see acute lar\mgitis) 
will usually bring about quick recovery and often prevent re- 
currence of the attack on the second or third night. 



CHRONIC LARYNGITIS. 961 

Persons, especially children, subject to laryngitis, should be 
careful to avoid exposure to cold and overuse of the voice, and 
must dress properly. The throat must not be bundled up too 
closely. Long-continued daily bathing of the throat in tepid 
and cold water tends to "harden" it. 

CHRONIC LARYNGITIS. 

^Etiology. — Attacks of acute laryngitis, especially when fre- 
quent, may be followed by the chronic form. Irritation of the 
throat from overuse of the voice, the tobacco-habit, or living 
in an atmosphere saturated with tobacco smoke or tobacco 
dust, the alcohol habit, and the existence of post-nasal catarrh, 
are other important causes. The latter is operative in very 
many cases, the nasal obstruction establishing mouth-breath- 
ing, or the catarrhal process affecting the vocal organs by con- 
tinuity of structures or by coming in contact with the foul 
discharge from the naso-pharynx. 

Symptoms. — The most constant symptom consists of 
changes in the timber of the voice. It grows rough, hoarse, 
unsteady and unreliable in speaking or singing ; sudden loss of 
control is common, even to complete stopping, from bits of 
mucus which drop between the vocal bands. At times the voice, 
hoarse and unsteady at first, clears up from use, and remains 
so until fatigued. Its range becomes restricted, a source of 
much distress to singers. During the dry months of the year 
this symptom may be quiescent, but shows itself promptly 
upon the appearance of damp weather. Cough is dry, hack- 
ing, harsh, usually provoked by tickling in the throat, worse 
during damp, cold weather, and followed by expectoration 
which generally is slight, lumpy or ropy, of varying color and 
consistency. Exceptionally it is copious. There is often pres- 
ent a desire to constantly clear the throat, which may become 
a fixed habit, sure to aggravate the local irritation. Rawness 
and dryness in the throat are persistent. The mirror shows 
swelling of the mucosa, which, however, lacks the intense red- 
ness of the acute inflammation. The symptoms are often mod- 
ified by the existence of other affections of which the laryngitis 
happens to be a sequel or complication. 

The course of the affection is tedious. While not immediately 
61 



962 DISEASES OF THE RESPIRATORY ORGANS. 

dangerous to life, it may, especially in persons inclined to tuber- 
culous disease, become a factor of serious importance ; hence, 
ever}' effort should be made to cure it. 

Treatment. — Experienced specialists, in addition to the cure 
of possibly existing nasal or naso-pharyngeal catarrh, lay much 
stress upon the necessity of teaching the patient a proper 
method of vocalizing, employing for this purpose, when possi- 
ble, a competent teacher of the voice. Ivins lays down the fol- 
lowing excellent rules : Sing or speak as little as possible when 
hoarse. Always pitch the voice low in conversation. Always 
sing with as little exertion as possible. Never sing higher than 
the easy compass of the voice, as nothing will be gained and 
much harm may result. Avoid straining the muscles of the 
pharynx in speaking or singing. Always breathe through the 
nose. Whatever irritates the larynx, as smoking, must be inter- 
dicted, and, if possible, exposure to dust or foul air is to be 
avoided. The general health must be energetically cared for, 
including the use of proper underwear, bathing, etc. A change 
of climate from the seaside inland, or vice versa, is often bene- 
ficial, even essential. 

Local treatment consist of measures for cleansing the parts 
(alkaline sprays, borax in solution of four grains to the ounce 
of water, Seiler's solution, permanganate of potassium), fol- 
lowed by stimulating applications, as chlorate of potassium, 
sulphate of zinc, or silver nitrate, the parts being carefully dried 
before using the latter. Peroxide of hydrogen, one part to 
three of water, is indicated when there is profuse secretion. 
Astringent applications (tannic acid, 5 grains to one ounce of 
glycerin) are beneficial when the mucous membrane is relaxed 
and "sluggish." The sprays or direct application by means of 
a laryngeal probe may be used with proper precautions. When 
possible, these cases should be sent to a specialist. 

Therapeutics. — Of the long list of remedies recommended, Ar- 
gent, nitr., Hepar sulph., Iodum, Kali bichrom., Phos- 
phorus and Gelsemium are the most useful. — Argentum ni- 
tricum. "Inflammation and swelling of the posterior wall and 
lining of the larynx, attended by a sensation of a clog in the 
vocal organ, with hoarseness or loss of voice, continual and 
vain efforts to swallow, with pain and soreness in deglutition, 
much hawking with considerable muco-purulent expectoration 



CHRONIC LARYNGITIS. 963 

or titillation in the larynx, with dry spasmodic cough" (Mey- 
hoffer). Public speakers and singers.— Arsenicum album. 
Dryness and burning, with sensitiveness of the larynx. Voice 
husky, without volume, easily tired out. Local anaemia. Par- 
oxysms of coughing, with scanty expectoration and asthmatic 
tendency. Irritability, weakness, nervousness. (Ars. iod. has 
of late years been extensively used.)— Calcarea carbonica. 
Involvement of the upper larynx. Hoarse cough. Discharge 
of thick, jelly-like mucus from larynx and naso-pharynx. The 
throat looks bluish from dilatation of veins ; raw feeling in the 
larynx; voice weak. Characteristic temperament; great 
dyspncea from going up-stairs. (Calc. iod.?)— Carbo yege- 
tabilis. Laryngeal rawness and soreness in old people ; pain- 
less dryness, with aphonia in the evening. Burning pain from 
coughing. Venous capillary dilatation of the pharynx and 
larynx. — Causticum. Hoarseness and loss of voice in singers 
and speakers. Paralysis of the vocal cords. Cough with 
scanty expectoration and sensation "as if he could not get 
under the mucus to raise it;" constant dry, hacking cough, 
with involuntary micturition. "Mucous lining anaemic; vocal 
bands gray or dingy in appearance, and are seen to come in 
contact, but separate before a tone is produced, the muscles 
being so weak that the respiratory current forces the muscles 
asunder" (Ivins). — Hepar sulphuris. Soreness and pain when 
talking or coughing; sensitiveness to cold air; hoarseness; 
loose, rattling mucus in the throat, with whistling sound in the 
larynx when he is lying down. Difficult expulsion of tenacious, 
scanty muco-purulent matter.— Iodum. Soreness of the larynx 
to touch; soreness of the larynx at one particular spot; dry, 
harsh cough, with expectoration of scanty, sticky lumps of 
mucus. — Kali bichromicum. Tenacious expectoration. 
"Scanty stringy expectoration, which can sometimes be seen 
stretching across the glottis from band to band. I have rarely 
seen failure when this symptom was present" (Ivins). "Vari- 
cose veins in the larynx.— Kali iodat. Raw, sore pain as if 
larynx were granulated. Scrofulous and syphilitic cases.— 
Manganum. Highly recommended, in the low triturations, by 
Meyhoffer. "Dryness and tickling in the larynx; hoarseness 
and loss of voice, the attempt to clear the larynx causing a sen- 
sation of rawness and sometimes stitches ; particularly valua- 



964 DISEASES OF THE RESPIRATORY ORGANS. 

ble for anasmic persons who are predisposed to catarrhal 
troubles. Expectoration scanty and tough ; cough worse from 
reading aloud, with dryness and rawness in the larynx. Copi- 
ous accumulation of mucus; roughness of the voice." (T. F. 
Allen).— Mercurius. Hoarseness; nocturnal cough, worse 
from lying on the right side. Swollen, livid appearance of the 
mucous membrane.— Phosphorus. Larynx sore, dry, so sensi- 
tive that talking is painful. Aphonia. Cough hoarse, with 
scanty expectoration. (Acts best in the higher attenuations.) — 
Kr ex crispus. Aphonia. Incessant dry cough, which seems 
to come from the pit of the throat, from taking a deep breath, 
worse from inspiring cold air.— Sanguinaria. Cough at night, 
with expectoration of offensive, thick mucus, sometimes tinged 
with blood. D^ness and swelling of the larynx. Loss of 
voice. Swallowing often painful.— Selenium. Paralysis of the 
vocal cords, hoarseness from singing or talking. Very valuable 
for the hoarseness of singers, especially when it is frequently 
necessary to clear the throat of clear, starchy mucus. Recom- 
mended by T. F. Allen, Meyhoffer, J. S. Mitchell, and others — 
Senega. "Loss of voice in singers, with severe burning and 
hawking. Catarrh of the larynx ; the voice is very unsteady, 
and the vocal cords are partially paralyzed ; sometimes expec- 
toration of tough mucus. Cough before breakfast" (T. F. 
Allen). Frequently clears the threat on account of colorless, 
starchy mucus. — Sulphur. Aphonia ; cough dry, worse at 
night, after lying down ; asthmatic tendency ; fatigue from 
talking. 

(EDEMATOUS LARYNGITIS. 

Acute laryngeal oedema or oedema of the glottis is a very se- 
rious affection, rapid in its development, and often fatal. It 
occurs in connection with acute or chronic inflammation of tis- 
sues adjacent to the glottis (acute laryngitis, syphilitic and 
tubercular laryngitis, cellulitis, erysipelas of the neck, diph- 
theria, etc.), in certain infectious diseases (scarlatina, enteric 
fever, typhoid fever), or in connection with affections liable to 
cause dropsy elsewhere (acute or chronic albuminuria). Its 
pathological features consist of extensive, pale swelling of the 
epiglottis, the infiltration being prominent in the ary-epiglotti- 



(EDEMATOUS LARYNGITIS. 965 

dean folds, which may meet in the middle line. The pallor of 
the swelling is not pronounced in the presence of intensely In- 
flammatory conditions of the larynx. The oedema is in the ma- 
jority of cases easily detected by the use of the mirror or it may 
be seen without the mirror if the tongue is strongly depressed ; 
it may also be felt by the finger. 

The symptoms are rapidly increasing difficulty of breathing, 
accompanied with shrill stridulous sounds, loss of voice, rapid 
small pulse, cold sweat, and frantic efforts to get breath. If 
the case improves, the distressing symptoms lessen in intensity, 
cough is followed by expectoration, and the patient drops into 
a refreshing sleep. No improvement taking place, death occurs 
from suffocation. 

The diagnosis is easily made. 

The prognosis is especially unfavorable when the oedema in- 
volves the parts below the glottis, in which event the case may 
terminate fatally within a few hours after the appearance of 
the first symptoms. 

Treatment consists of ice applied to the neck and taken in 
the mouth; leeches may sometimes be used advantageously ; oil 
of mustard and other irritants are advised. The atmosphere 
of the room should be charged with moisture and be kept at 
about 70° F. Steam inhalations may be employed, for a few 
minutes at a time, with precautions not to scald the throat. A 
4 per cent, cocaine spray upon the cedematous structures often 
affords relief. Tannic acid, in a strong aqueous solution of the 
glycerole, is also serviceable. Insufflations of dry powders, for 
evident reasons, are objectionable. However, not much time 
must be lost in using these mild measures. Unless improve- 
ment appears promptly, the parts must be scarified ; this trivial 
operation, by rupturing and emptying the sac, frequently gives 
immediate relief ; it may become necessary to repeat it. Intu- 
bation or tracheotomy may have to be performed; if the latter, 
the operation must not be too long delayed. — Apis is the most 
important remedy -when "the oedema occurs suddenly as a 
complication or sequence of burns or acute disease," for ex- 
ample erysipelas and the eruptive fevers. Parts glossy ; sting- 
ing pains.— Arsenicum. When associated with general anas- 
arca, cardiac affections, Bright's disease, etc. Low state.— La- 
chesis. In albuminuria. — Kali iod. in syphilitic cases.— 



966 DISEASES OF THE RESPIRATORY ORGANS. 

Sanguinaria, according to T. F. Allen, with sawing or rasping 
respiration, aphonia, dry and harsh cough, worse from lying 
down, scanty glairy expectoration. 



LARYNGISMUS STRIDULUS. 

This affection, still erroneously called thymic asthma and 
spasmodic croup, occurs in early childhood, hardly ever before 
the sixth month and rarely after the third year. It consists of 
spasmodic closure of the glottis (spasm of the adductor mus- 
cles), sometimes with spasmodic action of the diaphragm and 
other muscles of respiration. 

It is now generally admitted that the disease is of nervous 
origin, probable reflex from peripheral irritation. It is oftenest 
seen in puny, rickety infants, and in those subject to tetany. 
When there is a marked predisposition, trifles act as exciting 
causes of an attack ; thus, a scolding or slight punishment, or 
a fit of indigestion, or crying, are quite sufficient to throw the 
child into a severe paroxysm. In other cases they come on at 
night, without apparent provocation. The neurotic character 
of the trouble is not always understood bj- those in charge of 
the child, and the seizures are not infrequently treated as exhi- 
bitions of "temper." It is well to bear in mind the absence of 
any inflammatory action in the larynx and, hence, the inappro- 
priateness of here using the term "croup." 

Symptoms.— In the majority of cases no premonitory symp- 
toms are observed. If any warning is given, it is usually by a 
few "catches" in breathing; but there are no catarrhal symp- 
toms, hoarseness or cough, such as precede an attack of croup. 
There is simply a sudden and complete arrest of respiration, 
with struggling for breath, fixation of the muscles of the chest, 
and pallor, quickly followed by blueness of the face ; twitching 
of the face and carpo-pedal spasms are common; a violent 
bending backward of the body, closely resembling opisthoto- 
nos, is not infrequent ; general convulsions appear in excep- 
tional cases. Cyanosis develops rapidly, and with it brings 
relief of the spasm, the seizure ending with increasing relaxa- 
tion of the glottis and the somewhat labored inflation of the 
lungs with air, producing a characteristic prolonged, high- 



LARYNGISMUS STRIDULUS. 967 

pitched, crowing sound, often followed by coughing or crying. 
In rare cases impaction of the epiglottis or permanent cessation 
of breathing may cause death during the paroxysm. 

The attack may be frequently repeated during the day or 
night, and the affection may continue for months. 

The diagnosis presents no difficulty. It depends upon the 
absence of inflammatory symptoms in the larynx, the presence 
of a neurotic state, association with rickets or tetany, and the 
cessation of the spasm with the prolonged high-pitched sound 
upon inspiration. 

The treatment of the paroxysm requires promptness of ac- 
tion. The child must at once be raised to the sitting posture, 
cold water be dashed into the face, and face and chest lightly 
slapped with a wet towel. Ammonia may be held under the 
nose, and a sponge dipped in hot water be applied to the 
throat. Cold sponging is very efficient. The hot bath, how- 
ever, constitutes the most satisfactory treatment, and should 
be given as soon as it can be prepared. Care must be exercised 
not to scald the child ; cold water must be poured on the head 
and chest while the body is submerged. The introduction of 
the finger deep into the throat is advisable in prolonged at- 
tacks. Whiffs of chloroform serve well in exceptionally severe 
cases, and should be restricted to them. If all means fail, and 
death seems imminent, electricity (Faradism) may be applied, 
the positive pole to the spine, with the negative pole placed at 
the hypogastrium. Intubation and even tracheotomy may 
have to be performed. Death apparently having taken place, 
artificial respiration must be perseveringly performed to bring 
about resuscitation. 

The cure of the case depends upon the establishment of good 
health and the removal of exciting causes (undigested food, in- 
testinal worms, etc.). Attention must be paid to irritation 
arising from dentition. Circumcision may be indicated. The 
necessity of an appropriate, nourishing diet and careful atten- 
tion to all the details of the daily life of the infant need only be 
suggested. 

Therapeutics. — The internal administration of a remedy 
during the paroxysm itself is practically out of question, but 
a recurrence may be avoided, or the number and severity of re- 
currences favorably affected, by the exhibition of the indicated 



968 DISEASES OF THE RESPIRATORY ORGANS. 

remedy. The following are of especial service: Moschus (lx) 
has in my hands been the remedy par excellence. It is highly 
recommended by Kunze and other German clinicians. There is 
fine, wheezing inspiration, loss of breath, cyanosis, tetany. 
The attacks are brought on by laughing, crying or any nervous 
excitement, and are associated with spasmodic constriction of 
the larynx and chest and sense of impending suffocation. 
Threatening paralysis of the lungs. — Gelsemium is highly 
praised by J. S. Mitchell, who rarely finds any other remedy 
necessary. "Long inspiration, with short, sudden, violent expi- 
ration."— Sambucus. "Starts up in great suffocation, cannot 
exhale the breath, face grows purple." Between midnight and 
morning. Alternating spells of sweating and dryr heat.— 
Chlorine (dilute solution of chlorine gas) has made a good 
clinical record. Expiration is much more embarrassed than in- 
spiration; it is attended with a slightly crowing sound. Cya- 
nosis and partial unconsciousness. 

Consult also Arsenicum, Lachesis, Veratrum album, 
Cuprum, Ipecacuanha, Hyoscyamus, Belladonna, Ignatia. 
In cases of rickets Calcarea carbonica, Calcarea iodata, 
Iodum, Phosphorus, Silica and Sulphur should be carefully 
studied. 



PSEUDO-MEMBRANOUS LARYNGITIS. 

Pseudo-membranous laryngitis, membranous croup, or true 
croup, is so closely related to diphtheritic laryngitis that by 
many authorities it is simply treated as diphtheria involving 
the larynx. The arguments in favor of this position, from a 
clinical as well as from a bacteriological standpoint, are very 
strong, but not conclusive. The fact, however, that of thirty- 
six cases of croup, reported to the New York State Board of 
Health (1893) the Klebs-LcerHer bacillus was present in thirty, 
and that bacteriological examinations have established the 
presence of the specific micro-organism of diphtheria in about 
eighty-four per cent, of reported cases of pseudo-membranous 
laryngitis, shows that many special precautions heretofore lim- 
ited to diphtheria must, as a matter of safety, be practiced in 
presumed cases of membranous croup. 



PSEUDO-MEMBRANOUS LARYNGITIS. 969 

The essential feature, pathologically, is the formation on the 
inflamed laryngeal mucosa of a fibrinous exudation holding in 
its network necrotic epithelium and leucocytes. The exudate 
varies in color from a grayish- or yellowish-white to a dark, 
dirty brown when there is considerable extravasation of 
blood ; in thickness it may be a mere friable film resting upon 
the inflamed mucous membrane or the exudate may be thick, 
firm, tenacious, leathery. Owing to the fact that the laryngeal 
mucous membrane is covered with columnar ciliated epithelium, 
the membrane is much less deeply attached than is the case 
when the same exudate invades the pharynx ; hence it is de- 
tached with comparative ease and without leaving behind an 
extensively necrotic surface. The vocal cords and the inner sur- 
faces of the epiglottis are favorite seats of the exudation, 
which, though it may extend both upward and downward, in 
the majority of cases does the latter; hence the frequent in- 
tense dyspnoea in cases showing comparative freedom of the 
subglottic space from exudation. A tendency on part of the 
membrane to reform a second or third time constitutes one of 
the dangers of this disease. 

^Etiology.— True croup is a disease of childhood, seen with 
greatest frequency in the second and third year, rarely dur- 
ing the first and after the tenth year, and more often in boys 
than in girls. It usually occurs in winter and early spring, and 
in Eastern states is frequently brought on by exposure to a 
north or northeast wind. Cold and dampness are common ex- 
citing causes. Hereditary predisposition and low powers of re- 
sistance are factors of importance. One attack affords im- 
munity. 

Symptomatology. — The premonitory symptoms are indisposi- 
tion, with chilliness, slight fever, some hoarseness of voice, red- 
ness of pharynx, occasionally enlargement of the tonsils, and 
some cough. Often these symptoms appear at night, the child 
feeling somewhat better during the following day, but in the 
main slowly growing worse, with exacerbation of all the 
symptoms, especially the hoarseness and cough, during the 
night. 

Usually a few hours before midnight of the second or third 
day the disease fully declares itself by the appearance of a par- 
oxysm of intense dyspnoea, accompanied with symptoms of 



970 DISEASES OF THE RESPIRATORY ORGANS. 

threatening suffocation. Owing to the narrowness of the glot- 
tis, the amount of air which is allowed to pass is wholly insuffi- 
cient, and the patient, in an extremity of distress, calls to his 
aid every muscle which may be utilized in breathing. The inspi- 
ratory sound consists of a hard, prolonged, metallic, high- 
pitched, whistling, wheezing, stridulous sound, which is never 
forgotten ; the expiratory sound is low-pitched and snoring, 
accompanied with copious rattling of mucus. While thus suffer- 
ing, the child frantically clutches at the throat as though relief 
might be had by tearing it to pieces. The eyes are wild and 
staring ; the face expressive of mortal fright and despair, at first 
flushed, then cyanotic. Occasionally there is harsh, barking 
cough, sometimes in paroxysms of considerable severity ; after 
a time, hardly a sound is emitted with the cough. If the fila- 
ments of the bronchioles are involved, the dyspnoea becomes 
excessive. The respiratory efforts grow frantic ; the head is 
thrown far back, and the alae nasi expand and contract vio- 
lently. The inspiratory recession of the thorax indicates the 
muscular efforts put forth ; it is most pronounced in the supra- 
sternal and supra-clavicular regions and in the lower thorax, 
and may even lead to recession of the sternum. The duration 
of these attacks varies from a few minutes to a half-hour, or 
more, leaving the patient utterly exhausted. They recur at ir- 
regular intervals during which the child may have seizures of 
threatening suffocation, with no cough and slight, if any, spas- 
modic action, but otherwise equally distressing and exhausting. 
Should there be expulsion of membrane, great relief is at once 
experienced. Breathing becomes eas} r , the pulse steady, the 
cough almost ceases, the voice sounds natural, and the child 
eats and sleeps well. The improvement may continue to recov- 
ery. There is, however, danger that the deposit may reform, in 
which case the issue is doubtful. In the main, a distinct remis- 
sion and the ejection of pseudo-membrane is a favorable symp- 
tom. 

If there is no improvement, carbonic acid poisoning takes 
place, marking the beginning of the third stage, that of 
asphyxia. The child becomes restless, indifferent, stupid ; 
breathing is superficial and rapid, but comparatively quiet; 
the face becomes dusky, the lips livid, the hands mottled, the 
extremities cold, and the body is bathed in cold, clammy per- 



PSEUDO-MEMBRANOUS LARYNGITIS. 971 

spiration. The pulse is rapid, feeble and intermitting ; the sen- 
sibility of the skin is lost, stupor sets in, developing into coma, 
and death closes the scene. 

Of the complications which may arise, bronchial catarrh, 
bronchitis, pneumonia, pulmonary apoplexy and atelectasis are 
the more common. 

The duration of the diease is from four to six days, but cases 
often terminate fatally in from twenty-four to forty-eight 
hours. If there is reforming of the pseudo -membrane, the case 
may drag along for several weeks. 

The prognosis is bad, the fatality of the disease being vari- 
ously placed at from thirty to ninety per cent, of all cases. 

Diagnosis.— In the early stage the differentiation from spas- 
modic or false croup is impossible ; later the following points 
establish the diagnosis. False croup has more sudden inva- 
sion ; slight fever, hoarseness, cough and stridulous breathing 
disappear with the paroxysm; the paroxysm almost always 
comes on at night, with a condition of comfort during the day; 
recovery almost always after the third night. In pseudo-mem- 
branous croup the invasion is less sudden ; the cessation of the 
paroxysm does not give the same positive relief from cough, 
hoarseness, etc.; there is no distinct cessation of croup during 
the day, but a continuous growing worse day and night until 
recovery or death; the disease runs a longer course; there is 
expectoration of false membrane. 

Acute laryngitis attacks adults rather than children, and has 
painful deglutition. CEdema glottidis is a disease of adult life; 
it lacks the metallic, harsh cough of croup ; expiration is com- 
paratively natural ; there is no pseudo-membranous exudation ; 
it presents positive characteristic physical signs upon examina- 
tion of the parts. Retro-pharyngeal abscess has great difficulty 
of swallowing ; tumefaction and stiffness of the neck ; the phys- 
ical signs of a tumor ; dyspnoea is aggravated by attempts to 
swallow, by pressure on the larynx, and by lying down ; there is 
indistinctness of voice ; in croup, speech, though feeble, is dis- 
tinct ; relief is sought by bending the head backward, and swal- 
lowing is not so painful. The difficulty of differentiation from 
diphtheria has been pointed out; the absence of the Klebs- 
Loeffler bacillus, and the fact that the larynx is first attacked, 
are points in favor of a diagnosis of croup; it must further be 



972 DISEASES OF THE RESPIRATORY ORGANS. 

remembered that true croup is a disease of children, while diph- 
theria occurs in adults as well. 

Treatment. — It is a matter of good judgment to isolate the 
patient and to practice local and personal disinfection as in 
diphtheria. The sick-room must be kept at a temperature of 
from 70° to 80° F., saturated with moisture. Solis Cohen 
keeps the patient in a closed room, at a temperature of 80° con- 
tinuously maintained, with towels and cloths wet with hot 
water hanging all about the room. Water is constantly kept 
on the stove and grate. Or blankets may be arranged over the 
bed in the form of a tent or canopy, with an opening near the 
end for the purpose of ventilation, while through another open- 
ing near the middle of the "tent" a steady inflow of steam is 
kept up from a kettle by means of a tin pipe adjusted to the 
spout. A few drops of the oil of eucalyptus may be added to 
the water every few hours. The essential point is to secure a 
hot, moist atmosphere, and to maintain it until recovery is as- 
sured. The excellency of the plan is generally admitted. Di- 
rect applications to the larynx are out of question since the 
child is too uneasy to submit to any manipulation without se- 
rious risk of injuring the structures and thus inviting extension 
of the exudate. Inhalations of slaked lime or of bromine (one 
drachm of potassium bromide, one grain of bromine, one ounce 
of water) has proved of service in relieving the dyspnoea. It is 
also an excellent plan to spray the throat with a solution of 
bichloride of mercury (1 to 5000) or hydrogen peroxide (equal 
parts of ten-volume solution and of water). External applica- 
tions to the throat, as of cloths wrung out of hot water, are 
of slight value, since any benefit likely to be derived from them 
is more than offset by their pressure and the resulting addi- 
tional discomfort in breathing. The diet must consist of hot 
milk, with the addition of meat extracts, peptonoids, etc. Wa- 
ter may be drunk ad libitum. Alcoholic stimulants may be 
used throughout, if indicated hy the general condition of the 
case. Intubation and tracheotomy become a probable last re- 
sort in cases where the larynx is practically blocked b\- pseudo- 
membranous deposit. The uselessness of an operation after 
the exudate has invaded the bronchi is apparent. 

Therapeutics. — The exhibition of the proper remedy is of 
chief importance. In the early stage Aconite, Belladonna 



PSEUDO-MEMBRANOUS LARYNGITIS. 973 

or Ferrum phosphoricum are usually indicated by the symp- 
toms. In the second stage the choice of remedies will probably 
lie between Sanguinaria, Iodine and Kali bichromicum. — San- 
Guinaria, so far as its provings show, has a very decided action 
upon the respiratory organs, including the larynx, but not 
sufficiently profound to indicate its really great value in the 
treatment of this dangerous affection. There is much dryness 
of the throat, which feels swollen and constricted ; harsh, 
hoarse cough, sometimes almost continuous, again occurring 
in paroxysms, often metallic and whistling ; difficulty of breath- 
ing is great, labored "sawing," rasping; the voice is hoarse, 
sometimes lost, and there is occasional expectoration of tough, 
glairy mucus. The presence of fibrinous exudation in the 
pharynx and of symptoms which suggest the "diphtheritic" 
type of laryngitis are important indications for its use. I have 
had the best results from the Nitrate oe sanguinaria in the 
low triturations, combined with inhalations of watery solution 
of the same. Nichols highly recommends a syrup made by add- 
ing twenty grains of Sanguinaria to four ounces of vinegar, 
which is steeped, and then has added an ounce of sugar to form 
a syrup.— Iodine (given internally in one-drop doses of the 
strong solution every two hours and by inhalation in equally 
small doses) has made an excellent record in the hands of 
many of our best clinicians. T. F. Allen states "our experience 
is that it is indicated in cases in the early stage, with more or 
less fever, with dry skin and a very dry cough, great difficulty in 
respiration; It follows closely after Aconite; if Aconite has 
been given and the patient is not improving, or if Aconite has 
only relieved his restlessness and extreme anxiety, but not the 
cough, the patient is still dry and hot, and the cough still 
croupy, then give Iodine; it is, however, rarely useful after 
febrile excitement has disappeared or if the patient perspires 
freely." "(1) My own experience is fully in accord with that of 
Elb who recommends it in cases with violent fits of coughing, 
threatening suffocation, with whistling tone, and great 
anxiety; hissing, sawing, respiratory sound, painfulness of the 
larynx; hoarseness and red face, synochal fever; consequently 
at the first appearance of the disease. (2) When there are 
long-continued fits of loose-sounding coughing, without great 
danger of suffocation, which affords no relief; slight painful- 



974 DISEASES OF THE RESPIRATORY ORGANS. 

ness of the larynx ; strong sawing and hissing, but not whist- 
ling, respiratory sound ; temperature of the skin not elevated ; 
frequent, hard, but not full pulse. (3) Absence of cough or oc- 
casional short, loose-sounding, croupy cough; constant but 
moderate oppression on the chest ; rough, sawing, not whist- 
ling, respiratory sound ; cold, moist skin, small, hard, quick 
pulse. (4) Involvement of the bronchial ramifications, with 
absence of cough ; inaudible vesicular inspiration ; short, quick- 
ened respiration ; loss of voice, with weak, sawing, rather rat- 
tling respiratory sound ; pale, haggard countenance, cold, 
clammy sweat; small, rapid thready pulse." — Inhalation of 
iodine may be practiced by pouring a few drops of a fresh solu- 
tion of iodine into a shallow vessel containing hot water, di- 
recting the patient to bend the head over the vessel, thus inhal- 
ing the vapor. Old solutions of iodine are almost useless. — 
Kali bichromicum is especially indicated by the thickness and 
tenacity of the membrane and the ropy, tenacious character of 
the expectoration. There is a tendency to fibrinous deposits on 
the pharynx. Hoarse, barking cough, sawing respiration ; 
harsh, rough voice ; cool skin. — Less prominent, yet very useful, 
are: Arsenicum, with characteristic restlessness, fever, pros- 
tration, dyspnoea from oedema of the glottis.— Hepar sulph. 
Hoarse, rattling, croupy cough without expectoration ; diffi- 
cult inspiration, easy expiration ; only moderate embarrass- 
ment of breathing ; stitching pains from ear to ear. — Tartar 
emetic. In the late stage, with rattling of mucus in the 
throat and chest, but without expectoration ; great exhaus- 
tion, pallor, coldness of the surface, cold, clammy sweat and 
great difficulty of breathing. 
Consult Ipecacuanha, Bromine, Kali muriaticum, Mercu- 

RTUS CYANATUS, SPONGIA. 

SYPHILITIC LARYNGITIS. 

Syphilitic inflammation of the larynx is either inherited or ac- 
quired. 

The hereditary disease nearly always shows itself during the 
first six months of life ; occasionally it appears after puberty. 
The gummatous infiltrations tend to deep and extensive ulcer- 
ation, with probable deformity' or stenosis of the larynx from 
cicatricial formations. 



SYPHILITIC LARYNGITIS. 975 

The laryngeal manifestation of secondary syphilis consists 
of a catarrh which presents no characteristic features, with 
superficial and symmetrical ulcerations on the cords or ventric- 
ular bands. Mucous patches and condylomata are seen rarely. 
The symptoms consist of hoarseness and laryngeal irritation. 

Tertiary syphilis affects the larynx more frequently and more 
profoundly. True gummata, multiple or single, and varying in 
size from a pin's head to a hazel nut, appear in the submucous 
tissues, oftener at the base of the epiglottis. They may 
undergo resolution or break down ; if the latter, the ulceration 
is deep and extensive, often involving the cartilages, with dan- 
ger of serious haemorrhage from the erosion of the walls of 
blood-vessels or of sudden death from acute oedema. The 
presence of gummata is in itself capable of producing danger- 
ous narrowing of the larynx. The cicatricial formations 
which result from healing of the syphilitic ulceration may give 
rise to deformities of the larynx and stenosis, requiring for 
their radical cure operative treatment, including tracheotomy. 
The symptoms of this form are varied and intense, including 
loss of voice, hard cough, great pain, dysphagia and, later, re- 
spiratory embarrassment from mechanical obstruction. 

The diagnosis is rarely difficult in the presence of other symp- 
toms betraying the syphilitic origin of the affection. The char- 
acter of the ulceration and the offensiveness of the discharge 
are important helps. 

Treatment consists of keeping the parts clean and of the use 
of such local measures as will maintain a check upon the spread 
of the ulcers. (Cleanse the ulcer, then treat with cocaine, dry 
the parts, and cautiously apply a strong solution of silver ni- 
trate). 

Constitutional treatment is important, and consists of the 
exhibition of Potassium iodide or Mercury. J. S. Mitchell rec- 
ommends Mercurius corrosivus (6x trit.) as capable of 
promptly healing secondary ulcers with considerable secretion 
and inflammatory areola about the ulcer and expectoration of 
offensive sputa.— Kali iodatum in the tertiary form with rapid 
destruction of tissue, dry cough, burning sensation in the larynx. 
— Nitric acid: great soreness, bleeding, marked irritability. 

Consult also the remedies given under syphilis and tubercular 
laryngitis. 



976 DISEASES OF THE RESPIRATORY ORGANS. 

Cicatricial stenosis requires dilatation (Schrcetter) or trache- 
otomy. 



DISEASES OF THE BRONCHI. 

ACUTE BRONCHITIS. 

The term "acute bronchitis," as here used, means an acute 
catarrhal inflammation of the mucous membrane of all the 
bronchial tubes save the bronchioles ; inflammation of the lat- 
ter always involves the vesicular structures and constitutes a 
pathological entity described as "broncho-pneumonia." The 
use of the term "capillary" bronchitis is no longer allowable. 
The condition formerly described under this heading is either a 
true broncho-pneumonia or a catarrhal inflammation of the 
bronchial mucous membrane just stopping short of involve- 
ment of the bronchioles and vesicular structures, a condition 
which causes no characteristic clinical symptoms, no unmistak- 
able physical signs, and no constant post mortem appearances. 

^Etiology. — Primary bronchitis is usually the result of tak- 
ing cold, more frequently from exposure of some part of the 
surface of the body— as getting the feet wet, exposure to cold 
draught on the back, or sitting on the damp ground — than of 
the whole body. It occurs frequently in changeable, moist cli- 
mates, during the inclement seasons of fall and spring. It pre- 
ferably attacks children and persons enfeebled by age, ill health, 
physical exhaustion, close confinement, living amid unhealthful 
surroundings, or those of indolent and luxurious habits, or per- 
sons who are very susceptible to "colds," especially those who 
have suffered from previous attacks of bronchitis. It is often 
secondary to measles, influenza, whooping-cough, variola, and 
typhoid fever. Again, it may complicate certain affections of 
the pharynx (diphtheria), tuberculous or syphilitic laryngitis, 
or grave infectious diseases, such as typhus or typhoid fever, 
and certain diseases of the nervous system (locomotor ataxia, 
bulbar paralysis, etc.). 

Morbid Anatomy.— There is redness and hyperemia of the 
tracheal and bronchial mucous membrane, which is covered 
with mucus and muco-purulent matter ; desquamation of the 



ACUTE BRONCHITIS. 977 

ciliated epithelium ; swelling of the submucous structures ; in- 
filtration of tissue with leucocytes and distension of the smaller 
bronchi with mucus and muco-pus. The affection is bilateral. 

Symptomatology. — Bronchitis usually begins as a common 
cold, with some shivering, cold hands and feet, aching in the 
back and bones, sense of coldness "within" from the slightest 
draught and without any cause", some headache, a slight fever- 
ish condition, and scanty, watery coryza. The cold "works 
downward," getting into the larynx, trachea, then into the 
* 'chest," with symptoms characteristic of catarrh of the parts 
successively invaded. In severe cases there may be a slight 
fever, with a temperature of 101° to 103° F. Involvement of 
the bronchi is announced by a sensation of tightness and op- 
pression in the chest, with more or less rawness under the ster- 
num. The cough, at first laryngeal, becomes hard, ringing, al- 
most concussive, occurring in paroxysms which fairly tear the 
chest to pieces and greatly aggravate the soreness, especially 
beneath the sternum, in the intercostal spaces, and along the 
attachments of the diaphragm. The cough at first is dry; in 
a day or two it is followed by slight expectoration of mucus, 
which becomes more copious and muco-purulent, terminating in 
a free expectoration of purulent matter, with great relief of 
pain and soreness. Exceptionally, when the cough is unusually 
violent, the expectoration may be blood-streaked ; in the case 
of infants it is swallowed, and there may be gagging and vom- 
iting. The oppression and shortness of breathing are moder- 
ate, except when the finer tubes are involved or when there is 
excessive secretion of mucus. With the appearance of free ex- 
pectoration the general condition of the patient improves ; 
fever subsides and, in healthy adults, recovery usually follows 
in another week or ten days. 

In young children and aged people bronchitis is much more 
serious. In both, extension of the affection into the fine 
bronchi and even bronchioles is common, in children particu- 
larly when it is associated with measles, influenza or whoop- 
ing-cough. The fine tubes are filled with muco-purulent matter, 
and dilatation takes place, inducing areas of collapse and 
broncho-pneumonia. In old and feeble persons, inability to 
expel the accumulation, especially when the bases are exten- 
sively involved, leads to the same result. 
62 



978 DISEASES OF THE RESPIRATORY ORGANS. 

Physical Signs. — There is, in mild cases, slight increase of re- 
spiratory movements, greatly exaggerated when the fever is 
high or the finer tubes are involved. Palpation reveals bron- 
chial fremitus. Upon auscultation sibilant rales are heard in 
the early stage, which disappear with coughing. If the case is 
mild and only affects the large tubes, these may be indistinct. 
Later, with increasing freedom of secretion and relaxation of 
the mucous membrane, the rales become coarse and bubbling. 
Extension into the fine tubes, in children, is accompanied with 
subcrepitant rales, areas of defective resonance, and feeble or 
distinct tubular breathing. 

The prognosis in healtlry adults is good, convalescence taking 
place in a week or ten days after the appearance of free expec- 
toration ; if neglected, or after repeated attacks, the disease 
may assume the chronic form. In infants and very feeble 
adults, and in the aged, bronchitis is always serious. 

The diagnosis is easy, and there is rarely difficulty in differen- 
tiating bronchitis from fibrous pneumonia or whooping-cough. 
Localized bronchial catarrh, unilateral, is well calculated to 
arouse suspicion, especially when occurring at the apex or 
apices of the lungs, since it often is the first objective sign of 
pulmonary consumption. 

Treatment.— A mild case requires little attention be3 r ond 
such common-sensemeasures as are familiar to all. A copious 
sweating is always advisable, provided caution is taken to pre- 
vent catching additional cold. A hot foot bath at night, with a 
hot lemonade taken just before going tc bed, accomplishes this 
purpose. A Turkish bath is objectionable and dangerous be- 
cause of exposure in returning home from the bath. Even in 
light cases the patient should remain indoors until the attack 
has passed away. If there is fever, it becomes necessary to 
keep the bed and to maintain in the room an even temperature 
which, during the stage cf dry cough and rawness in the chest, 
should be thoroughly saturated with moisture. A wet compress 
or a mustard draft on the chest is unobjectionable, and usually 
relieves pain. Young children and old people should receive 
careful attention from the first. The former, if there is any 
fever, should be put into a hot bath, two or three times during 
the day, cold water being applied, while in the bath, to the 
head and chest. Or the wet pack may be used, wrapping the 



ACUTE BRONCHITIS. 979 

child in a sheet wrung out of water at a temperature of 68° to 
75°, with a flannel blanket outside, the pack to be renewed two 
or three times during the day. The bath and wet pack favor 
free expectoration and exert a favorable influence on the course 
of the disease, materially lessening the danger of invasion of 
the fine tubes. Proper precautions against taking cold must, 
of course, be observed. If, in the case of young children, expec- 
toration ceases, there is great difficulty of breathing and the 
skin and nails become blue, it is then safe and advisable to 
give an emetic, preferably a tablespoonful of the wine of ipe- 
cacuanha ; this may be repeated, if necessary. 

The universal use of opium for the relief of the cough is un- 
necessary, save in very exceptional cases, and then minute 
doses of 3^ of a grain, repeated a few times, usually answers the 
purpose. In children and in old and feeble people morphine is 
exceedingly dangerous. 

The diet should be nourishing, but light. Hot drinks may be 
given freely. In the case of children and the aged feeding is im- 
portant, for their strength must be sustained to the fullest ex- 
tent possible. Alcoholic stimulants, especially in old people, 
are indicated. 

Whatever increases the tone of the system and its powers of 
resistance, and strengthens the respiratory apparatus in per- 
sons predisposed to bronchial and pulmonary disease, comes 
under the head of prophylaxis. Here belongs attention to 
proper clothing, care in avoiding exposure to drafts or incle- 
ment weather, systematic bathing and sponging of throat and 
chest in tepid or cold water, and such breathing-exercises as aid 
in the development of a weak chest. 

Therapeutics. — At the beginning Aconite is usually indi- 
cated by its characteristic restlessness, pulse, fever, cough, 
thirst, etc. The cough is dry, hard, ringing, worse after drink- 
ing cold water and from lying on either side ; better from lying 
on the back. The breath is hot. Urine diminished, hot, dark, 
red-brown, turbid ; the restlessness is increased before urinat- 
ing, and the act itself is sometimes painful. — Veratkum viride 
is called for in cases of exceptional violence from the first, with 
great dryness and heat of the body, high temperature, full, 
hard, rapid, bounding pulse ; tendency to stupor, and bloody or 
blood-streaked expectoration. 



980 DISEASES OF THE RESPIRATORY ORGANS. 

Later the choice usually lies between : Belladonna. Con- 
gestive type ; great heat ; dry, spasmodic cough, especially at 
night; expectoration of bloody mucus. — Bryonia. Dry, tear- 
ing cough, especially at night, with substernal irritation, often 
terminating in a fit of vomiting ; sharp pleuritic pains, worse 
at night and from motion.— Calcarea carbonica. Tickling in 
the throat as from a feather, from talking ; yellow, thick, fetid 
expectoration ; children of characteristic temperament, with 
enlarged cervical glands.— Drosera. Convulsive, spasmodic 
cough, something like whooping-cough, from tickling in the 
throat ; coughing and vomiting ; expectoration of gray, yellow, 
greenish color. — Ferrum phosphoricum. Sharp, short, spas- 
modic cough ; moderate fever and restlessness ; painful cough, 
oppression and dyspnoea ; expectoration clear or blood-streaked. 
— Hepar sulph. Deep, dry, harsh cough ; cough loose and rat- 
tling, worse from inhaling cold air and toward morning. Sore- 
ness in the chest ; substernal stitches ; wheezing inspiration. — 
Kali bichromicum. Hoarse, whistling cough, excited by tick- 
ling in the throat, with tenacious, stringy expectoration. It 
comes from low down in the chest and is worse from eating and 
in the morning. — Pulsatilla. Rather mild cases. Dry cough 
or an easy cough with free expectoration of thick, yellow mu- 
cus. Cough becomes dry and spasmodic at night, and con- 
tinues so during the night. Worse in a warm room.— Sangui- 
naria. Soreness, burning and stitching pain in the chest. Dry 
cough, with dryness and sense of constriction in the larynx 
and chest. Tickling and crawling sensation under the sternum. 
Scant}', glairy expectoration.— Rumex. Cough dry, incessant, 
with tickling in the larynx and trachea ; great sensitiveness to 
cool or cold air, which at once aggravates the cough ; he even 
covers up his head to avoid inhaling cold air. Cough worse in 
the morning and at night ; it seems to come from behind the 
sternum. — Spongia. Wheezing, asthmatic cough, sometimes 
with profuse expectoration and suffocative attacks; cough 
better from eating, worse in a hot room and from lying with 
the head low. Hoarseness. — Souilla. Violent rattling of 
mucus in the chest, which is raised after much effort and in 
small amounts, followed by relief. Cough brought on by 
drinking; spasmodic; with involuntary micturition.— Stan- 
num. Cough dry in the early part of the night ; during the day 



CHRONIC BRONCHITIS. 981 

expectoration of solid lumps of mucus of sweetish taste ; salty 
expectoration ; cough worse from talking, laughing, lying on 
the right side, taking warm drinks ; great weakness in the chest 
and weak voice. 

In cases of involvement of the fine bronchi or threatening 
broncho-pneumonia the following are important: Phos- 
phorus. Full hard pulse and high temperature. Later, great 
weakness ; feeble and rapid pulse ; frothy expectoration ; dry, 
short cough, caused by excitement of any kind and seemingly 
proceeding from the pit of the stomach ; night cough ; great 
oppression of breathing. — Ipecacuanha. Exceedingly valua- 
ble in children when there seems to be a complete filling up 
with mucus, with spasmodic cough, retching and vomiting of 
large quantities of phlegm. Cough with threatening suffoca- 
tion.— Tartar emetic. Filling up of the air passages with 
mucus, causing great dyspnoea, even to threatening suffoca- 
tion ; constant wheezing and rattling of the chest, cold clammy 
sweat, utter prostration. Threatening paralysis of the lungs 
in children and old people. (The low triturations should be 
used here.)— Arsenicum has proved helpful in severe cases, with 
extreme dyspnoea, great exhaustion of the nervous system, 
characteristic excessive restlessness, even to anguish, cold 
sweating, etc. The cough is worse after midnight and from 
lying on the back. Expectoration is scanty. 

In mild cases of bronchitis, with an asthmatic tendency, loud 
rales and weak action of the heart, Grindelia robusta, in 
drop-doses of the mother tincture, often proves helpful. 

CHRONIC BRONCHITIS. 

Etiology. — Chronic bronchitis is a disease of advanced years, 
rarely occurring in the young. It frequently follows repeated 
attacks of acute bronchitis, but often is seen as a secondary 
affection to cardiac or renal disease, pulmonary phthisis, rheu- 
matism or gout. Men are its victims oftener than women. 

Pathological Anatomy. — Chronic hyperaemia, with thicken- 
ing and swelling of the mucous membrane, is common ; atrophy 
of all the layers is, however, frequently seen in old cases. Bron- 
chiectasis and emphysema in varying degree are always pres- 
ent. 



982 DISEASES OF THE RESPIRATORY ORGANS. 

Symptoms. — Distinct varieties are recognized, each present- 
ing a distinct clinical history. Of these, the so-called Winter 
cough or bronchitis of old men is the most common. It is pe- 
culiar to old people, and is troublesome chiefly during the cold, 
damp and changeable months of the year, frequently disap- 
pearing regularly during the dry, warm months of summer. 
The cough itself varies. In some cases it is almost constant; 
in others, a paroxysm in the morning, of varying duration and 
intensity, affords relief for the succeeding twenty -four hours ; 
again, the patient may cough little during the day, but is kept 
awake all night, in aggravated cases coughing almost inces- 
santly. Expectoration is usually abundant and of a muco- 
purulent character ; rarely there is no expectoration. There is 
almost always considerable shortness of breath, a good deal of 
wheezing and puffing, and in some cases considerable difficulty 
in ascending stairs or an elevation, owing to existing emphy- 
sema and cardiac weakness. 

General health is not especially affected ; there is rarely fever, 
save with an intercurring acute parox3 r sm ; but the duration 
of the affection is indefinite, and a cure often impossible. The 
physical signs are hyper-resonance upon percussion ; prolonged 
expiration, with wheezy rhonchi of greatly varying pitch and 
quality upon auscultation, and usually considerable crepita- 
tion at the bases. 

Dry catarrh (catarrhe sec of Laennec) has very scanty secre- 
tion. Cough occurs in violent and distressing paroxysms, 
often of long duration, with redness of the face, swelling of the 
veins, and great muscular effort, followed by scanty expectora- 
tion of tough, stringy, semi-transparent mucus. Patients of 
this class often suffer from emphysema and severe attacks of 
asthma. Auscultation yields sibilant rhonchi, but no rales. 
General health is good. The affection is intensely chronic. 

Bronchorrhoea (bronchial blennorrhoea) consists of violent 
paroxysms of coughing with expectoration of serous, sero- 
mucous, or muco-purulent matter, which may be blood-stained 
if the paroxysm of coughing has been unusually severe. In 
some cases the amount raised is scanty, but usually it is very 
large, frequently exceeding a pint in the twenty-four hours. If 
allowed to stand in the sputa-cup, the purulent part of the ex- 
pectoration sinks to the bottom, the frothy sero-mucus re- 



CHRONIC BRONCHITIS. 983 

maining on top. It is seen chiefly in connection with cardiac 
affections. General health suffers comparatively little, save as 
considerable emaciation may occur in cases of more than com- 
mon severity. The duration is indefinite, often many years, 
unless death occurs from disease of the heart. Abundant moist 
rales are heard in the lower lung ; these are much diminished 
after copious expectoration. Bronchiectasis is pronounced. 
A somewhat rare form was described by Laennec (catarrhe 
pituiteux, true bronchorrhoea, humid asthma), in -which in- 
tensely severe paroxysms of coughing, usually at night and 
lasting from half-an-hour to an hour, or more, accompanied 
with severe respiratory symptoms, are followed by the expec- 
toration of enormous amounts — even one to two quarts in 
twenty-four hours — of thin, frothy, purely serous sputum. In 
these cases abundant and extensive moist rales are heard, with 
slightly lessened or normal resonance on percussion. 

Putrid or fetid bronchitis occurs in connection with bron- 
chiectasis, gangrene or abscess of the lungs, or from the en- 
trance of b&cteria of putrefaction into the contents of a tuber- 
culous cavity, or in empyema. It is rarely primary. Its 
appearance in a case is rather sudden, and is preceded by a 
chill and elevation of temperature. Its most characteristic 
feature is the horribly offensive character of the secretion. The 
expectoration, upon standing, separates into three layers : an 
upper layer, frothy and muco-purulent ; a middle layer of 
scanty, greenish sero-albuminous fluid ; and a lower, yellowish- 
green, purulent sediment, containing small, rather more solid, 
cheesy masses, casts of the finer bronchi, which crumble under 
pressure and emit the fetor. ("Dittrich's plugs.") The affec- 
tion is rare and very obstinate. It continues for years, some- 
times for life, with exacerbations and remissions of varying 
duration. It may lead to pneumonia, pulmonary abscess or 
gangrene ; abscess of the brain has occurred from metastasis. 

Treatment. — When within the reach of the patient, a summer 
residence away from the dust and dirt of the city, preferably 
near the sea, should be insisted upon, with a winter home in 
some Southern state, as Florida; still better is a permanent 
residence in Southern California. Such a change of climate 
does not lessen the necessity of attempting to remove the 
primary cause of the chronic bronchitis and of medical treat- 



984 DISEASES OF THE RESPIRATORY ORGANS. 

ment, but it affords chances of recovery under treatment which 
cannot be had otherwise. Persons who are not able to afford 
a change of climate must exercise the utmost care to fortify 
themselves against changes of weather and to reduce to a 
minimum all chances of avoidable exposure. If their occupa- 
tion is unwholesome, it must be changed. The house must be 
kept well ventilated and at an even temperature (from 68° to 
70°). Underwear and upper garments must be adapted to the 
seasons of the year ; particular pains are to be taken at the 
approach of warm weather not to discard prematurely the 
heavy winter-underwear. The feet must be kept warm and 
dry. Bathing the chest and throat in cold water, followed by 
brisk rubbing, is highly important. Chest protectors are for- 
bidden. Drafts and badfy ventilated or badly heated rooms, 
as theatres and other public places, cannot be visited with 
safety during the greater part of the year. In damp, cold days 
the patient must remain in the house ; otherwise he is to live 
in the open air as much as possible, e\^en though it may be 
cold. Stimulants may be used in moderation. 

Inhalations are of much benefit, if properly used. In dry 
catarrh, a ten-per cent, solution of sodium chloride or of bicar- 
bonate of soda, used by steam atomizer, affords much relief. 
If the secretion is abundant, inhalations of turpentine, persist- 
ently followed, are excellent. A teaspoonful of turpentine may 
be added to a small vessel of boiling water and the steam in- 
haled as it arises, or the so-called turpentine-pipe may be used. 
The latter consist of a flask partly filled with water, on the 
top of which rests a thin layer of oil of turpentine ( or of oleum 
pinus pumilionis). Two glass tubes, open at both ends, are 
passed through the cork. One of these extends into the layer 
of water ; the lower end of the other is left free in the upper 
part of the flask, the upper end, bent at a proper angle, form- 
ing the mouth piece of the "pipe." The latter the patient 
sucks, and may thus for an indefinite length of time inhale the 
turpentine-laden air. Inhalations of eucalyptus are also use- 
ful. Turpentine may also be administered internally, from five 
to ten drops in a capsule. Terpin hydrate, from four to six 
grains, taken three or four times a day before eating, checks 
the expectoration, and must therefore be used with some care. 

Fetid bronchitis requires the use, by steam atomizer, of a 



CHRONIC BRONCHITIS. 985 

two- or five-per cent, solution of carbolic acid, or of thymol (1 
to 1000) or of ten drops of a solution containing equal parts 
of terebene, carbolic acid, and spirit of chloroform. These 
should be used from three to five minutes at a time, three or 
four times daily. It is also necessary to keep a strong disin- 
fectant, as carbolic acid, in the sputa-cup, and to frequently 
spray with a ten-per cent, solution of carbolic acid the room 
which the patient occupies. Myrtol, in five-grain doses inter- 
nally and as an inhalation, lessens the expectoration and the 
fetor. 

The primary affection must not be neglected, and complica- 
tions are to be met as they arise. 

Therapeutics. — The remedies to be exhibited are largely 
those discussed under "Acute Bronchitis." Dr. Hale (Practice 
of Medicine) furnishes an excellent chapter on "cough reme- 
dies" which deserves careful study. — Ammonium carbonicum is 
a valuable remedy in the chronic bronchitis of old people (with 
emphysema), with constant tickling in the larynx and under 
the sternum, loose and rattling cough, with scanty, sometimes 
blood-streaked, expectoration, accompanied with much debility 
and shortness of breath. — Ammonium muriaticum is not so 
often indicated, but acts well when the cough is violent and 
dry, but becomes loose in the afternoon, with much rattling of 
mucus, copious expectoration, and coldness between the 
shoulder blades. — Arsenicum is highly recommended by J. S. 
Mitchell in fetid bronchitis. "In all forms of chronic bronchitis 
of old people it is useful in mitigating the asthmatic symptoms 
and relieving the irritative symptoms." — Causticum. Excep- 
tionally, with characteristic laryngeal complications, loss of 
voice, etc. — Copaiva. Profuse, easy, purulent expectoration. 
(Hale gives two minims on sugar disks.) — Cubeba. Tearing 
cough, with difficult expectoration of stringy, white or gray 
mucus. — Drosera. Severe paroxysms of hoarse, harsh cough, 
ending in vomiting, especially at night, immediately after lying 
down. — Eucalyptus. Bronchitis with profuse expectoration. 
— Kali carbonicum. Dry, paroxysmal, suffocative cough, 
with sharp, cutting pain in the sides of the chest and hypo- 
chondria. Attack of asthma three to four a. m. Patient 
weak, • short-breathed. Scanty, difficult expectoration of 
sticky, grayish mucus. — Rumex crispus. Sensitiveness to cold 



986 DISEASES OF THE RESPIRATORY ORGANS. 

air; incessant dr\- cough. Asthma and sense of suffocation, 
worse at two a. m. — Senega. Difficult raising of tough, pro- 
fuse mucus, with hard, loud breathing, anxiety, sensation of 
weight in the chest, and soreness of the chest walls. Cough 
worse in the evening, at night, lying on the right side. — Silica. 
Expectoration transparent or opaque, tough and tenacious. 
Meyhoffer thinks it essential to the cure of the "catarrhe 
pituiteux" of Laennec. — Sulphur. Cough attended with 
heaviness of the head and dim vision. Expectoration of large 
quantities of tenacious mucus, or scanty, yellowish, white 
sputa; putrid bronchitis, after the suppression of eruption; 
gouty and rheumatic diathesis. Sensitiveness of the skin to 
atmospheric changes. — Hale recommends the iodides as a class ; 
Iodide of lithia when of gouty origin ; Iodide of potassium 
when humid asthma is present. 

FIBRINOUS BRONCHITIS. 

Fibrinous, croupous, pseudo-membranous or plastic bron- 
chitis is a rare acute or chronic disease of the bronchial mu- 
cous membrane, characterized by the formation of pseudo- 
membranous casts in the tubes, which are expelled in par- 
oxysms of great dyspnoea and coughing. The term is restricted 
to that form in which the fibrinous deposit occurs primarily in 
the bronchi, and is never applied to secondary involvement 
arising in diphtheria, croupous pneumonia, or other diseases ol 
the lung. 

./Etiology. — Very little is known of the causation of this affec- 
tion. It is very rare, but appears to occur oftener in males 
during the third and fourth decade of life. It has been known 
to attack several members of one family and to assume almost 
endemic features. The greater number of cases were observed 
in spring. It is frequently associated with pulmonary tuber- 
culosis and appears to have a vague relation to the menstrual 
period ; it has also been seen in the course of acute infectious 
diseases (typhoid fever) and in connection with pemphigus, 
herpes, and impetigo. 

The pathology of the disease is obscure. The most striking 
and as yet unexplained features are the preference for certain 
territories in the lung and the recurrence of the fibrinous for- 



FIBRINOUS BRONCHITIS. 987 

mation throughout a period of varying length, sometimes at 
regular stated intervals. The pseudo-membrane itself is dis- 
tinctly "croupous," but of an unusual degree of density. 

Symptomatology. — The acute form resembles a severe acute 
bronchitis, with fever, cough, dyspnoea, sometimes haemop- 
tysis. The expulsion of the fibrinous coagulum may occur 
early or after several days, and is always associated with a se- 
vere paroxysm of choking and coughing. The attack may last 
a few days or several weeks. The prognosis is grave, with 
fatal termination in from 25 to 50 per cent, of all the cases 
within fourteen days. The chronic form is somewhat milder, 
but presents very much the same picture, with recurring at- 
tacks, at greatly varying intervals, for a period which may 
cover many years. Bronchitis always exists, frequently with 
very slight, if any, fever. The cough is harassing, frequently 
in paroxysms ; dyspnoea is usually pronounced and often very 
distressing ; the expectoration may be stained or streaked with 
blood, and moderate haemoptysis is not unusual. The expul- 
sion of the pseudo-membrane is followed by relief of the urgent 
symptoms. The prognosis here is much more favorable than 
in the acute form. The physical signs of bronchitis, theoretic- 
ally, should be present and well marked; in actual practice 
they are vague and recognized with considerable difficulty. 

The diagnosis depends entirely upon the presence of the fibri- 
nous cast. This may be found by thoroughly washing the 
coagulum in water. It is tough, elastic, yellowish- white, con- 
stituting a perfect cast of a bronchus of the second or third 
order with all its final ramifications, varying in length and 
thickness, the larger tube usually being hollow and of the size 
of a small goose-quill, the smaller, solid and threadlike. The 
membrane shows a definite laminated structure. Hyaline 
transformation of the fibrin is not unusual. Leucocytes and 
red blood corpuscles are imbedded in the fibrous network, 
while alveolar epithelium and carbon particles are frequently 
seen in the lumen of the smaller twigs. Since the bronchi in the 
upper lung subdivide more rapidly than those in the lower 
portion, the appearance and size of the cast serves to locate the 
seat of the affection. 

Treatment. — The treatment is that of bronchitis. Inhalation 
of ether, atomized lime water and steam aids in the expulsion 



988 DISEASES OF THE RESPIRATORY ORGANS. 

of the membrane. An emetic may become necessary for the ac- 
complishment of this purpose. Of internal remedies, Phos- 
phorus deserves especial consideration. 

BRONCHIECTASIS. 

Bronchiectasis or dilatation of the bronchial tubes occurs in 
chronic bronchitis and emphysema, broncho-pneumonia of 
children, from the presence of a foreign body in the air tubes 
or the compression of a bronchus by an aneurism. In these 
cases the operative causes are weakening of the walls from 
atrophy of the tissues which follows inflammation, with re- 
sultant inability to withstand the air-pressure during severe 
paroxysms of coughing and the weight and pressure of accu- 
mulated secretions. In other cases this condition is brought 
on by forces from without, traction upon the walls of the 
bronchi being made by the contraction of the fibrous frame- 
work of the lungs ; this condition obtains in chronic pleurisy, 
cirrhosis of the lung, and chronic pulmonary tuberculosis 
Very rarely bronchiectasis is congenital ; when congenital, it 
is always unilateral. 

Two forms are distinguished : the cylindrical and the saccu- 
lar. The former is usually the result of chronic bronchitis, with 
emphysema, whooping cough, measles, phthisis. It affects the 
bronchi of the second and third order. It is very difficult of 
recognition during life. The saccular form consists of oval or 
spherical dilatations, in size varying from a pea to an orange ; 
these develop gradually and sometimes freely communicate 
with each other ; again they ma} r form a closed cavit} r . Dense 
fibrous tissue separates the sacculi. The walls consist of a thin 
membrane, the original bronchial wall in a state of extreme atro- 
phy ; occasionally the structures have undergone hypertrophy, 
and band-like projections and swellings are noticed. Erosions 
and ulcerations may take place in the dependent part and extend 
into the surrounding tissue, constituting a pus cavity. The 
dilatations are almost always multiple and surrounded by 
hardened, contracted lung tissue. A single bronchiectasy, sur- 
rounded b}' normal lung tissue, is rare ; it may occur in bron- 
chitis and emphysema. The contents of the larger cavities are 
excessively fetid. 

Symptoms. — Characteristic S3 r mptoms arise only in connec- 



BRONCHIAL ASTHMA. 989 

tion with the larger bronchiectases, and then refer to the pecu- 
liarities of cough and expectoration. The cough conies on at 
considerable intervals and is followed by characteristic expec- 
toration. Oftenest coughing occurs in the morning, the secre- 
tion having accumulated during the night. Again, a change 
in position, by causing an outflow of the secretion into the 
normal tube, may bring on a fit of coughing with copious ex- 
pectoration. The expectorated substance is fluid, grayish or 
grayish-brown, of a peculiar sour odor, sometimes horribly 
fetid. If allowed to stand and settle, it separates into a thick, 
granular layer below, then a thin serous, slightly mucoid layer, 
and a brownish froth on top. The sedimental layer consists 
largely of pus corpuscles and bundles of fatty acid crystals ; 
hasmatoidin crystals and elastic fibres are present when there 
is ulceration. Nummular expectoration, as pertains to phthisis, 
is not common. Haemoptysis is rare. 

The diagnosis of a large bronchiectatic cavity lying near the 
surface of the lung is not difficult ; it presents clearly marked 
cavernous sounds and amphoric signs, with impaired reso- 
nance, bronchial respiration, and increased vocal fremitus over 
the adjacent surface. Such cavities are usually found near the 
base of the lungs ; the sounds necessarily vary as the cavity is 
full or empty. Moderate and even quite large bronchiectases 
lying deep within the substance of the lung rarely yield reliable 
physical signs. Struempell lays down the rule that the more 
abundant the formation of bronchiectases, the more does the 
respiration lose its vesicular character and become hard and 
finally bronchial. 

The course of the affection depends upon the primary disease 
of which it usually is a serious complication, not infrequently 
causing pulmonary gangrene^ tuberculosis, or other grave con- 
ditions. On the other hand, it may exist for many years in an 
extensive form and cause only slight disability. 

The treatment must be directed to the primary disease. If 
the expectoration is very offensive, methods advised under 
"fetid bronchitis " are to be followed here. 

BRONCHIAL ASTHMA. 

An affection which is characterized by recurring paroxysms 
of urgent dyspnoea, with cough and expectoration. 



990 DISEASES OF THE RESPIRATORY ORGANS. 

Etiology. — The causation of asthma is still involved in 
doubt, although the presence of the neurotic element is rec- 
ognized by all. It is probable that the essential feature is a 
considerable hyperemia and swelling (vaso-motor turgescence) 
of the mucous membrane lining the fine bronchi or the bron- 
chioles, due to direct irritation or irritation brought about by 
reflex influences. As pointed out by Osier, this hypothesis, 
more readily than any other, explains the respiratory embar- 
rassment, the quality of the rales, and the presence of viscid, 
tenacious mucus during the paroxysm. A family tendency to 
asthma is noticeable, and most pronounced in those of a neu- 
rotic temperament ; it may be associated with other expres- 
sions of neurosis, as neuralgia or epilepsy. Climate is a factor ; 
yet it is closely allied with idiosjmcrasy, some persons suffer- 
ing from asthma only at certain seasons or in certain localities 
which fail to produce the same results in other victims of the 
disease. Sometimes breathing the air of some particular room 
or the odor of some flower, emanations from certain animals, 
or excitement, as a fit of anger or a fright, will bring on an 
attack. Bronchitis is closely connected with a large majority 
of all cases; affections of the nose, especially hypertrophic rhi- 
nitis and nasal polypi, rank next ; hence the necessity of avoid- 
ing "taking cold." Uterine and ovarian disease, gout, indiges- 
tion, etc., may by exciting reflex action precipitate an attack 
of asthma. 

Symptoms. — In some cases premonitory symptoms are 
noted, such as might suggest having taken cold or laboring 
under unusual mental depression. In the greater number of 
cases the patient is roused from sleep by difficult and labored 
breathing, which increases rapidly, culminating in a paroxysm 
of agonizing dj^spnoea. The number of respirations is not 
greatly, if at all, increased, but the inspiratory effort is intense, 
calling into requisition the full force of all the accessory mus- 
cles, with hardly any success; expiration is prolonged and 
wheezy. The general appearance of the patient bears witness 
to the distress experienced; if prolonged, the face is bathed in 
cold sweat, the pulse becomes fluttering, the extremities cold, 
and the condition seems one of imminent danger, when the 
paroxysm yields, breathing becomes easier, and, often after a 
spell of coughing, the patient finds rest and sleep. These 



BRONCHIAL ASTHMA. 991 

attacks may last from a few minutes to an hour, or longer, 
and may recur for days at varying intervals. The physical 
signs during an attack are : enlargement and fixation of the 
thorax, involving the diaphragm ; short, quick, labored inspir- 
ation; prolonged, often wheezing, expiration. Auscultation 
yields a great variety of rales, sibilant, high-pitched, hoarse 
and, later, moist. 

The sputum consists of small, opaque, round, gelatinous 
balls or pellets (perles of Laennec), held in thin mucus. Un- 
folded, these represent moulds in mucus of the smaller tubes. 
Under the microscope they show a curious spiral structure, 
fully described by Curschmann, presumably the product of an 
acute bronchiolitis. After the sputum has assumed a muco- 
purulent character, which it does in two or three days, the 
spirals disappear. They are thoroughly characteristic of bron- 
chial asthma in the early stage. 

Treatment.— The treatment of the paroxysm itself consists 
of such measures as will relax the spasmodically contracted 
bronchi. To this end, nitre paper (made by soaking soft paper 
in a strong solution of potassium nitrate) may be burned in 
the room ; cigarettes containing stramonium, belladonna, 
lobelia or tobacco often are smoked by the patient and afford 
relief. If these are not sufficient, a few whiffs of chloroform, or 
the inhalation of two to four drops of amyl nitrite on a hand- 
kerchief, or the hypodermic injection of morphine (alone or 
with cocaine) may meet the emergency. Inhalations of 
oxygen or of compressed air in a pneumatic cabinet have each 
their warm advocates. The radical treatment includes the 
cure of the bronchitis, rhinitis or other disease which is respon- 
sible for the occurrence of asthma. If associated with other 
manifestations of a neurotic character, these will necessarily 
determine the course to be followed. In the latter class of 
cases, as in those associated with bronchitis, the climate plays 
an important part. Its selection is purely experimental, 
although in the greater number of cases a moderate elevation 
and dryness of the atmosphere yield better results than the 
seashore ; but frequent exceptions to this rule exist, as my ex- 
perience here on the Pacific shore has repeatedly demonstrated. 
It is safe to assert that Southern California, in some locality, 
meets the conditions of almost every case of bronchial asthma. 



992 DISEASES OF THE RESPIRATORY ORGANS. 

In reference to diet, Osier suggests the wisdom of not eating 
freery of carbohydrates, of using coffee rather than tea, of tak- 
ing heavy meals in the early part of the day, and of not retir- 
ing to bed before gastric digestion is completed. 

Therapeutics. — The most valuable remedies are Arsenicum, 
Cuprum, Moschus, Grindelia, Ipecacuanha.— Arsenicum has 
a specific action upon the bronchioles, causing a train of symp- 
toms in the provers which strikingly resembles bronchial 
asthma. Extreme anxiet} T ; short anxious breathing ; difficult 
breathing, with anguish ; asthmatic cough ; nocturnal aggra- 
vations and nightly paroxysms of asthma are parts of its 
pathogenes}". It is especially useful in dn- asthma, and acts 
well in the aged, feeble and exhausted. — Cuprum apppears to 
act best when the attacks appear and disappear suddenly, and 
"when the spasmodic character overshadows all other phe- 
nomena." "Blueness of the face, constriction of the throat, 
intense dyspnoea, retching and vomiting" (T. F. Allen). 
Spasms of the hands and feet. — Moschus, given low, is invalu- 
able when the neurotic element predominates. Hysterical 
symptoms often are present. The chest seems filled with 
mucus, causing fine sibilant rales throughout. The patient is 
perfectly wild from fear of impending suffocation. There is 
sense of intense constriction in the chest, almost cramplike. — 
Grindelia robusta has done excellent service in attacks de- 
pending upon chronic bronchitis, particularly in people of ma- 
ture and somewhat advanced \^ears who had passed through 
several attacks of "la grippe" and were left with an "asth- 
matic tendency." When in such cases, upon slight exposure, 
the difficult breathing is gradually increased until it becomes a 
violent paroxysm of asthma, with large coarse bubbling rales, 
copious string}- expectoration, with often slight nausea and 
faintness at the heart, the effects of this remedy are prompt 
and permanent. — Ipecacuanha, with many practitioners, 
seems to have lost its old-time reputation in asthma, but I still 
find it very useful when there is bronchitis with large rales or 
when the parox\^sm of asthma is characterized by much de- 
pression and a sense of faintness which appears to overcome 
the patient. Though evidently suffering intensely, he makes 
comparatively slight effort to help himself, and appears as 
though there were not energy enough in him to "resist the 
current." 



DISEASES OF THE PARENCHYMA OF THE LUNGS. 993 

Other remedies to be consulted are: Aconite. According to 
Mitchell, in healthy, robust adults, with characteristic restless- 
ness, hard, bounding pulse, etc. Intense violence of the symp- 
toms. — Bromine. Spasmodic constriction which, it seems, pre- 
vents his breathing; better at and near the sea. Asthma of 
sailors which occurs as soon as they go on shore. — Lachesis. 
Asthma of reflex origin. Unwillingness to bear the slightest 
pressure about the neck or chest. The dyspnoea awakens him. 
— Nux vomica and Pulsatilla, when due to indigestion.— San- 
guinaria when there is a history of hay-fever. — Sulphur in 
very tedious cases ; suppression of some skin eruption ; bron- 
chitis ; "fits of suffocation" in the early part of the night, and 
with burning in the chest. Expectoration of "whitish or yel- 
lowish mucus. Attacks recurring at regular periods (eight 
days ?) and in the morning. — Tartar emetic, in children and 
old people; characteristic bubbling rales in the chest, with 
great dyspnoea, coldness of the extremities, cold sweat, etc. 

Clinicians of the dominant school use potassium iodide in 
chronic asthma, giving it in small, increasing doses. Salter 
affirms that it cures one case in five of chronic asthma. 



DISEASES OP THE PARENCHYMA OP THE 
LUNGS. 

DISTURBANCES OK CIRCULATION IN THE LUNGS. 

Pulmonary congestion is active or passive. Active conges- 
tion occurs when an unusual amount of blood is forced into 
the lungs by increased action of the heart (as from violent ex- 
ercise) and from the inhalation of very hot air or irritating 
substances ; to a more limited extent it is associated with in- 
flammatory action from any cause in the lungs, the interfer- 
ence with the capillary circulation resulting in congestion and 
distension of the adjacent non-inflamed tissues. The symptoms 
closely resemble those of an inflammation, with defective reso- 
nance, fine rales and impeded, sometimes bronchial, breathing. 
Death may result, especially from cases due to excessive exer- 
tion (as rowing) and exposure to extreme heat. 

Passive pulmonary congestion is mechanical or hypostatic. 
63 



994 DISEASES OF THE RESPIRATORY ORGANS. 

Mechanical congestion results from inability of the left heart 
to take its full amount of blood ; hence this affection is com- 
mon in disease of the left heart and in the presence of tumors 
capable of similarly interfering with the circulation. Upon 
section the lung tissue is found firm and resistant to the knife 
and of russet-brown color (brown induration of the lungs), 
which changes to a vivid red, from oxidation of the haemo- 
globin, upon exposure to the air. Hypostatic congestion is 
seen in protracted cases of typhoid fever and in profoundly 
adynamic states generally. The bases of the lungs are chiefly 
involved, especialfy posteriorly. The lung tissue, upon section, 
is found gorged with blood and serum, and portions of it sink 
in water (splenization; Irypostatic pneumonia). It has also 
been seen in organic disease of the brain, as cerebral apoplexy. 

The treatment is directed to the cause. Free bleeding (from 
twenty to thirty ounces of blood) from the arm may be neces- 
sary when the pulmonary congestion is excessive. The reme- 
dies are selected from S3 r mptomatic indications. 

CEdema results from the transudation of serum from en- 
gorged capillaries into the air cells and alveolar walls ; hence, 
it is common in congestion and inflammation of the pulmon- 
ary structure. It may be limited to the immediate neighbor- 
hood of the portion involved (collateral oedema) or be general. 
It probably often occurs as a feature of the death-agon}^. The 
condition in a greater number of cases depends upon weakness 
of the left ventricle, resulting in congestion of the pulmonary 
capillaries, tension and transudation, favored by a dilute, 
watered state of the blood plasma. Post mortem, the involved 
structure is found heavy, infiltrated, water-laden, with copious 
escape of clear or blood}- serum upon section. 

The symptoms are those of increasing cough and d} r spnoea. 
When oedema develops suddenly, it may prove rapidly fatal 
(as in Bright's disease). 

Treatment is symptomatic. Apis, Arsenicum, and remedies 
of this class, must be considered. Active catharsis is advised 
in severe acute cases. 

Pulmonary haemorrhage occurs frequently. The blood is 
either poured into the bronchial tubes and then expectorated 
(broncho-pulmonary haemorrhage, haemoptysis, bronchor- 
rhagia) or the haemorrhage takes place into the air cells and 



DISTURBANCES OF CIRCULATION IN THE LUNGS. 995 

lung tissue (pulmonary apoplexy ; pneumonorrhagia ; haemor- 
rhagic infarct). 

Haemoptysis or blood-spitting is due to a great variety of 
causes and is not necessarily an expression of disease. Thus, 
plethoric persons, especially young men, may bleed quite freely 
when in the enjoyment of perfect health and without experienc- 
ing an untoward symptom. Spitting of blood when ascending 
a mountain is often the result of increased action of the heart 
and change in atmospheric pressure. As a symptom of disease 
it occurs in: Pulmonary tuberculosis, in the early stage or 
after local lesions have formed. It may be bronchial, or due to 
erosion of the walls of a blood-vessel or the bursting of an 
aneurismal dilatation. The early stage of pneumonia, cancer, 
gangrene, abscess, bronchiectasis. Diseases of the heart, espe- 
cially of the mitral valve ; here it usually is copious and may 
recur at long intervals. Ulceration of the larynx, trachea, 
bronchi; usually due to the erosion of walls of vessels (as a 
branch of the pulmonary artery), hence copious. Aneurism. 
Among the rarer forms may be mentioned the vicarious haemop- 
tysis in interrupted menstruation, that of malignant fevers 
and purpura hemorrhagica, the pulmonary bleeding of persons 
of an arthritic history, usually occurring in men over fifty 
years of age, and the endemic haemoptysis seen in some por- 
tions of China and Japan, which is caused by the presence of 
an animal parasite, one of the Distomidae, in the bronchi. 

Symptoms. — There are no premonitory symptoms. A sense 
of fulness in the chest, occasionally slight pain, is followed by 
a warm, sweetish taste in the mouth, slight cough, and the ex- 
pectoration of blood. The bleeding may be of short duration 
or continue more or less constantly for days. It is not usually 
copious enough to excite alarm, unless due to the erosion of a 
vessel or the rupture of an aneurism, in which case an actual 
inundation of the lung may take place "with, of course, fatal re- 
sults. A free haemorrhage may take place into a cavity, and 
cause death without external signs. In the greater number of 
cases the bleeding after a time grows less and less, and finally 
ceases spontaneously, with, for days, slight and decreasing 
traces of blood in the expectoration. A portion of the blood 
may be swallowed and vomited up or passed with the stool. 
The haemorrhage having ceased, the patient is soon restored to 



996 DISEASES OF THE RESPIRATORY ORGANS. 

his usual health, and often appears to feel the better for it. 
Recurrences may, however, occur at any time. 

The blood of haemoptysis is alkaline in reaction, usually 
bright, frothy, mixed with mucus and, after coagulating, 
shows air bubbles in the clot. It is sometimes possible to de- 
tect blood moulds of the smaller bronchi. 

Pulmonary apoplexy is the result of "blocking" of some 
branch of the pulmonary artery by a thrombus or an embolus, 
as frequently occurs in chronic cardiac disease ; but blocking or 
even total obstruction does not necessarily result in haemor- 
rhage into the corresponding lung area. The infarctions most 
frequently occur near the surface of the lung, and are oftenest 
wedge-shaped, with the base toward the periphery. They 
vary in size from that of a walnut to an orange, and may even 
fill the greater part of a lobe. The}- are of dark color, hard, 
firm, and possess the structural properties of a blood-clot. If 
the bleeding is not fatal, reestablishment of the circulation and 
removal of the clot ma}' occur ; more frequently the clot under- 
goes the usual changes, leaving a fibroid, puckered patch. 
Again, sloughing may occur, a cavity be formed, and even gan- 
grene result. 

The symptoms are very indefinite, and the diagnosis resolves 
itself into a "suspicion" of the existence of an infarct, based 
upon the occurrence of haemoptysis in connection with cardiac 
disease, especially mitral stenosis. 

Treatment of Haemoptysis.— It is necessary to insure quiet 
in bed, which in the majority of cases is quite sufficient to stop 
the bleeding; the importance of this simple, common-sense 
measure cannot be overestimated. The patient, when the cir- 
cumstances justify it, must be assured that comparatively 
slight danger exists. The physician must abstain from exami- 
nation of the chest, especially- from percussing it. The usual 
home-treatment, drinking a solution of a teaspoonful, or two, ■ 
of common salt in water or very sour lemonade, is not to be 
commended ; it disturbs the stomach and does more harm 
than good. 

When haemorrhage results from erosion and perforation of 
the walls of an artery of some size, the blood being raised in 
large mouthfuls, the outlook is necessarily serious, and little can 
be done to avert an unfavorable issue. A ligature put around 



DISTURBANCES OF CIRCULATION IN THE LUNGS. 997 

the leg, or Esmarch's bandage, will temporarily check it, but 
it is of slight permanent benefit. 

It is well to remember that the fainting which is pretty sure 
to occur sooner or later favors the formation of a thrombus, 
and may thus assist in saving the patient. Serious danger 
arises from the accumulation of blood in the bronchial tubes, 
practically an inundation of the parts ; the patient, therefore, 
should be encouraged to cough up the blood, and opium, which 
lessens the cough, should under no circumstances be exhibited. 

When the bleeding occurs from the bronchial mucous mem- 
brane, the indications are absolute quiet and rest in bed and 
the exhibition of such agents as will reduce blood pressure ; for 
the latter purpose Aconite, Opium and, if necessary, "salts" 
are most effective; Digitalis and alcoholic stimulants are 
contra-indicated. Ice may be sucked ad libitum; the diet must 
be simple, light and non-stimulating. 

Therapeutics.— Arnica. Blood dark, coagulated; stitching 
and bruised soreness in the chest. — Aconite. Great vascular 
excitement, flushed face, constant cough ; sensation of heat in 
the chest ; the blood is bright-red, mixed with mucus ; blood 
coagulates quickly. Anxiety ; fear of death. — Cactus. Much 
cardiac excitement. Copious haemorrhage of bright-red blood. 
Band-like constriction in the chest and about the heart. — 
Hamamelis. Purpura haemorrhagica ; malignant fever. Dark 
blood. — Ipecacuanha. Expectoration of frothy, bloody mu- 
cus; sensation of bubbling in the chest; faint and out of 
breath; in tubercular cases.— Ledum palustre. Bright-red, 
frothy haemorrhage. Haemoptysis " alternating with attacks 
of rheumatism" (T. F. Allen). Cough violent, spasmodic; 
pulse strong. — Millefolium. Profuse flow of bright-red 
blood, which is thin; oppression and palpitation; not much 
cough; blood is raised without cough; "only distinguished 
from Aconite by the absence of anxiety." In tuberculosis. — 
Veratrum viride. Intense arterial excitement, with heavy,' 
full pulse ; the patient seems calm and indifferent ; blood flows 
in large quantities ; it fairly spurts from the mouth. 

Consult also Arsenicum, Ferrum, Phosphorus, Bella- 
donna, Erigeron, Ruta, Sanguinaria, Bryonia, Senecio. 



998 DISEASES OF THE RESPIRATORY ORGANS. 

PNEUMONIA. 

Lobar (croupous or fibrinous) pneumonia, pneumonitis, 
lung-fever, is an acute infectious disease, localized in the lungs, 
but followed by general infection, with high fever, pains in the 
chest, expectoration of gelatinous, rusty-colored sputum, con- 
solidation of the lung tissue, termination of fever by crisis, and 
second ary infectious processes. 

/Etiology. — Pneumonia is a common disease, in frequency of 
occurrence ranking next to tuberculosis ; statistics show that 
it constitutes about three per cent., and furnishes a mortality 
of 6.6 per cent., of all diseases. It shows no preference for any 
time of life, but is espeeialry fatal in the aged. It attacks men 
oftener than women. Climate seems to exert slight influence, 
since pneumonia is found everj^where ; in the United States it 
is more frequent in the South than in the northern states. The 
season of the year during which it is most prevalent is from 
December to May, especially February and March. It is evi- 
dent that severe cold weather, as is had in January, does not 
in itself especially favor pneumonia, but that a large daily 
range of temperature and sudden changes are far more import- 
ant. It is much more frequent among city people than in the 
country, and a hardy life out-of-doors protects against it; 
thus, observation shows that soldiers have pneumonia much 
oftener in garrison than while engaged in active duty in the 
field, and sailors when on shore rather than on the sea ; among 
washer-women in Paris the death rate from pneumonia was 
3.05, while among nuns it reached 7.02, per thousand. Here, 
as elsewhere, whatever weakens the vigor of the constitution, 
and thus lessens the power of resistance, becomes a predispos- 
ing cause. Hence the alcohol habit, life amidst unhealthful 
surroundings, disease (espeeialry chronic albuminuria, diabetes, 
tedious diseases of the nervous system, low and protracted 
fevers) must be mentioned here. A feature of especial interest 
is the fact that one attack of pneumonia strongly predisposes 
to recurrences of the disease. 

The common belief that pneumonia is the result "of a cold " 
is probably incorrect. The contagiousness of the disease is not 
settled, and the weight of evidence is against it ; but it often 
occurs in an almost epidemic form in certain houses, establish- 
ments, and restricted neighborhoods. 



PNEUMONIA. 999 

The specific cause of pneumonia is now held to be the micro- 
coccus lanceonatus (Fraenkel, 1886, though earlier described 
by Sternberg). It is lancet-shaped, occurs in pairs (hence di- 
plococcus), sometimes in rows or beads of five or six, or more, 
elements ; in the body, it is also seen encapsulated. It is found 
in the buccal secretion of healthy persons, and in many parts 
of the body, as the nose, larynx, Eustachian tubes, pleura, 
kidneys, etc. It persists for an indefinite time in the saliva of 
those who have had pneumonia, and is seen in secondary pro- 
cesses, as endocarditis, pleuritis, etc. The view now generally 
entertained is that the diplococcus enters the lung, sets up a 
specific inflammation there, producing also a poisonous albu- 
min (pneumotoxin) which, by absorption, causes the constitu- 
tional symptoms of the disease ; in the course of time, it is held, 
there is produced in the body a substance (antipneumotoxin) 
which has the power of neutralizing the effects of the pneumo- 
toxin, the crisis occurring when this stage has been reached. 

Morbid Anatomy. — Pneumonia affects the lower portion of 
one lung, or the entire lung, preferably on the right side, or 
portions of both lungs, preferably the lower. The stage of en- 
gorgement, lasting from several hours to several days, is char- 
acterized by a congested state of the lung tissue, which is firm, 
solid, deep-red, and on the surface bathed in a bloody serum. 
The capillaries are distended, and the air spaces filled with red 
and white blood corpuscles, granular matter, fibrin and epithe- 
lial cells. The inflammatory product in the air spaces and 
bronchi having reached the maximum of its development, the 
second stage begins, that of red hepatization. The lung tissue 
is now solid and airless, sinking in water. The surface is dry, 
brown and somewhat granular ; the lung substance friable, so 
it is easily torn, even under common manipulation. Upon sec- 
tion, granulation is readily seen, the granules representing 
plugs consisting of inflammatory products which fill the air 
cells. The smaller bronchi are often filled with fibrinous plugs ; 
infiltration of leucocytes into the interlobular tissues is marked. 
The affected lobe is increased in size, compressing other parts 
of the lung, and often showing the indentation of the ribs. The 
pleura is covered with fibrinous exudation. 

The stage of gray hepatization consists of degeneration and 
breaking-up of the exudation preparatory to its removal, in 



1000 DISEASES OF THE RESPIRATORY ORGANS. 

case of recovery, by the lymphatics. The fibrinous network 
disappears, red blood corpuscles are no longer seen, and leu- 
cocytes abound in the air cells. The parts are bathed in a pur- 
ulent fluid, and the term "purulent infiltration" naturally sug- 
gests itself as descriptive of this state. Resolution consist in 
the removal of the softened exudate and cell elements by the 
lymphatics ; it may be characterized b}^ the incidental forma- 
tion of abscesses. 

The duration of the different stages varies. The change from 
red to gray hepatization proceeds with varying rapidity in dif- 
ferent parts of the affected lung, so that both types of hepati- 
zation ma}' exist at the same time. The unaffected portion of 
the lung usually is congested or oedematous. The bronchial 
mucosa, after death, is found congested, but not swollen ; the 
tubes are filled with frothy, serous fluid, and in the affected 
parts with plugs and even casts. The bronchial glands are 
swollen, sometimes pulpy. The pleura appears slightly turbid 
under a thin covering of fibrinous exudate. The heart, espe- 
cially the right chamber, is distended with firm, solid coagula. 
Pericarditis, endocarditis and meningitis are sometimes seen ; 
parenchymatous, and other, changes of the liver and kidney are 
not infrequent ; the spleen is frequently enlarged ; croupous or 
diphtheritic inflammation has been observed in other parts 
(as croupous colitis). 

Symptoms. — The onset of the disease is either sudden or 
marked by indisposition which rarely continues longer than 
two days. More frequently — in about 90 per cent, of all cases 
— a severe, intense chill racks the patient for ten to thirty min- 
utes ; sometimes the chill is repeated. This is followed at once 
by a rapidly rising temperature. With the fever, a severe, 
agonizing and stead} 1 - pain in the side appears, followed by 
short, dry, painful cough, with somewhat rapid and restricted 
breathing. The fever continues, with a fall of one degree or 
one and one-half degrees in the morning. The other S3^mptoms 
show no abatement. The patient lies on the affected side or 
on the back, breathing hurriedly and, often, with much diffi- 
culty on account of the severe chest pain ; the alae nasi expand 
with each inspiration ; the face looks dark-red, sometimes only 
on the affected side ; the eyes appear bright-red and lustrous ; 
the pulse is full and bounding. The cough is frequent, has a 



PNEUMONIA. 1001 

peculiar metallic ring, and is painful ; when obliged to cough, 
the patient endeavors to find relief of pain by firmly pressing 
his hand upon the side. The expectoration is at first light and 
frothy, but soon becomes viscid, tenacious and rust-colored ; 
occasionally it becomes dark, like prune-juice. It indicates 
inflammatory involvement of the air cells, and is found in no 
other condition. This state persists until, sometimes as early 
as the third day from the appearance of the initial chill, oftener 
from the fifth to the tenth day, a crisis takes place. The fever 
subsides, with relief of all the symptoms, and, in the absence of 
complications, convalescence may be considered established. 
Occasionally defervescence takes place by lysis. 

Physical Signs. — Inspection shows deficient expansion of the 
affected side after consolidation has taken place; this is also 
shown by palpation. Mensuration may demonstrate enlarge- 
ment of the affected side. Percussion in the early stage yields 
a high-pitched, rather tympanitic note ; later the sound be- 
comes dull, flat. Auscultation early gives a "harsh, loud, 
puerile, respiratory murmur" (Stokes) or at the end of each 
inspiration a fine crackling sound close to the ear ; when the 
patient is directed to draw a long breath, harsh broncho-ves- 
icular sounds are heard. Tubular breathing is heard in the 
second stage, often intense, and frequently without rales. "It 
is simply the propagation of the laryngeal and tracheal sounds 
through the bronchi and the consolidated lung tissue. The 
permeability of the bronchi is essential to its production. 
Tubular breathing is absent in certain cases of massive pneu- 
monia in which the larger bronchi are completely filled with 
exudation" (Osier). Bronchophony, dulness on percussion, 
and bronchial breathing constitute the three most marked 
signs of hepatization. 

Special Symptoms. — Fever may reach its maximum within 
the first three days, possibly during the first twenty-four 
hours. The average temperature is from 102° to 103° in the 
A. m., and 104° in the afternoon of the same day, the height of 
the temperature usually being in proportion to the intensity of 
the disease. Defervescence in most cases begins on the seventh 
day, next in order of frequency on the fifth, sixth, eighth or 
ninth day. A sudden rise in the temperature means an exten- 
sion of the pneumonia or some complication. It is especially 



1002 DISEASES OF THE RESPIRATORY ORGANS. 

significant when occurring during the period of defervescence, 
and means a possible pleuritis, abscess or, less often, gangrene. 
A subnormal temperature is unfavorable. If the temperature 
drops rapidly, possibly heart failure must be anticipated. 

The pulse, after the chill has passed, is full and bounding, 
rarely dicrotic, and ranges from 100 to 120 ; if over 120, it 
may be considered a danger signal. In old persons it may be 
small and rapid. The heart-sounds are loud and normal, with 
accentuation, according to some observers, of the second heart- 
sound over the pulmonary artery. Heart failure, it is thought, 
occurs here as in diphtheria from the constitutional effects of 
the toxalbumin, with increasing smallness and rapidity of the 
pulse, followed by cessation of the heart's action. Embryo- 
cardia is often noticed in connection with heart failure. This 
accident is likely to occur during rapid defervescence or on the 
day before defervescence becomes established, and when there is 
chronic endocarditis. The blood is rich in fibrin ; leucocytosis 
is usually present ; in fact, Osier states that absence of leuco- 
cytes means danger of malignant pneumonia. Diplococci are 
rarely seen in the blood under the microscope. Pain in the 
side, usually at the nipple, in the axillary region, or in the 
flank of the affected side, less often below the shoulder blade, is 
early and severe ; it maj^ disappear after three or four days ; 
and may be trifling or wholly absent in old people. It is 
severe, "steady," aggravated from coughing and breathing. 
Breathing is superficial and rapid, from forty to sixty respira- 
tions to the minute in adults and from fifty to seventy in chil- 
dren, the result of nervous influence, fever, loss of function in 
the affected tissues, and pain. The inspirations are short and 
superficial ; the expirations are accompanied with a half-groan 
or "grunt." The ratio between pulse and respiration is one 
to two, and more. Cough is short, frequent, painful. Excep- 
tionally it is deferred until resolution begins. In children and 
old people it ma}" be absent throughout. The expectoration is 
exceedingly tenacious, and often must be removed from the lips 
by a napkin ; later it becomes more liquid. It consists of the 
contents of the inflamed air cells, and has the rust} r -colored, 
and in "low" cases the "prune-juice," appearance already de- 
scribed. Labial herpes are very common. The tongue is usually 
furred white; continued moisture is a good sign. The urine 



PNEUMONIA. 1003 

is of high color, high specific gravity, dense, of acid reaction. 
Urea and uric acid are increased, the chlorides lessened. If the 
kidneys are involved, casts and albumin in moderate amount 
are present ; bile pigments are seen in jaundice. 

Cerebral symptoms consist of headache and delirium. Head- 
ache of a dull, heavy character is common, but delirium is rare, 
save in children, of whom a large number are delirious and 
may have convulsions, and in drunkards, who may present 
the symptoms of delirium tremens. Healthy adults usually re- 
tain consciousness throughout, but delirium in such cases, 
when it occurs, is likely to be violent and may result in perma- 
nent insanity. Delirium in either case is usually accompanied 
with high fever. 

Complications. — Pleurisy, more or less pronounced, exists 
when pneumonia affects the periphery of the lung ; sometimes 
its symptoms overshadow the pneumonia (pleuro-pneumonia). 
If it occurs as a clear-cut complication, it usually appears on 
the sixth or seventh day. It is characterized by copious effu- 
sion, rich in fibrin, and empyema ; breathing is feeble ; there are 
no rales; continued or extended dulness at the base. Catar- 
rhal Bronchitis, affecting the larger bronchi of both lungs, is 
not infrequent in the pneumonia of epidemic influenza. There 
is copious mucous expectoration, abundant coarse rales, 
sibilant and sonorous breathing, great dyspnoea, elevation of 
temperature, venous congestion, tendency to heart-failure. 
Acute pericarditis is observed in connection with double 
pneumonia or pneumonia of the left side; often in children. 
It is not necessarily fatal. Symptoms : Increase of dyspnoea, 
increasing feebleness of the pulse, gradual suppression of heart- 
sounds. Acute endocarditis is not uncommon, but is difficult 
of recognition. It occurs oftener in the left heart than in the 
right and when there is a history of valvular disease. Accord- 
ing to Osier, it may be suspected in cases in which the fever is 
protracted and irregular ; when signs of septic mischief arise, 
such as chills and sweats ; when embolic phenomena appear. 
Fatty degeneration of the myocardium has been noticed. 
Meningitis is not a frequent, but a very serious, complication. 
It may not be recognized, except when it involves the base of 
the brain. There may be embolism of the cerebral arteries, 
with hemiplegia. Other and rare complications seen are: 



1004 DISEASES OF THE RESPIRATORY ORGANS. 

B right's disease (pneumonia occurring in persons suffering from 
chronic nephritis usually proves fatal), croupous colitis, 
croupous gastritis, arthritis, parotitis. 

Recurrences of pneumonia are frequent, and cases in which 
the patient has had the disease six or eight times are not un- 
common ; relapses are so rare that the possibility of their oc- 
currence is denied by mam^. 

Clinical Varieties and Peculiarities of Pneumonia. — Various 
terms are used in connection with pneumonia to describe some 
clinical peculiarity, as "adynamic," "bilious," "malarial," 
"rheumatic," etc. The term "typhoid" pneumonia must not 
be used interchangeably with "pneumo-typhus," a typhoid 
fever beginning with a pneumonia. Larval pneumonia refers 
to cases occurring during epidemics of pneumonia which have 
mild initial symptoms of the disease without clearly pro- 
nounced local signs. Migratory (or creeping) pneumonia at- 
tacks first one lobe, then the other ; the extension of the dis- 
ease is marked by violent exacerbation of all the symptoms. 

Double pneumonia means a simultaneous involvement of 
both lungs ; it is characterized by decided increase of the diffi- 
culty in breathing and probability" of fatal termination. Mas- 
sive pneumonia means a pneumonia with involvement of both 
air cells and bronchi of the entire lobe or lung. The physical 
signs are like those of pleuris\ r with effusion. There is neither 
fremitus nor tubular breathing; absolute flatness on percus- 
sion. Molds of the bronchi may be expectorated. The mor- 
tality is great. Epidemics of pneumonia are usually attended 
with a high mortality rate. The clinical history presents no 
variation from the regular form, but in nearly every epidemic 
some special feature common to all cases is emphasized ; thus 
in some epidemics diarrhoea is prominent ; in others, cardiac 
complications or cerebral symptoms are very pronounced. The 
so-called infectious cases present an intensity of constitutional 
manifestations which is out of proportion to the local affection, 
and strongly suggests toxic action. The temperature is high, 
the tongue dry, the action of the heart rapid and weak, brain 
symptoms pronounced, and the fatality great. 

The following facts are of interest : In infants, cerebral symp- 
toms and convulsions are common, even early in the course of 
the disease ; the apices of the lungs are involved much oftener 



PNEUMONIA. 1005 

than in adults; there is very commonly an entire absence of the 
characteristic rust-colored sputum. In the aged all the symp- 
toms and physical signs may be vague, with hardly any chill, 
fever, cough, expectoration, pain or difficulty of breathing. 
The prostration, however, is remarkable, and death may occur 
suddenly even in apparently light cases. In drunkards there is 
the striking predominance of brain-symptoms and delirium 
already described ; the onset is usually insidious and the fever 
slight. In diabetes the course is rapid and severe, often ending 
in abscess or gangrene. Usually involvement of the apices 
occurs when there is great adynamia ; chiefly in infants ; cere- 
bral symptoms are severe ; cough and expectoration often 
slight. 

Prognosis. — Pneumonia in private practice has proved fatal 
in from 20 to 25 per cent, of all the cases, in hospital practice 
in from 18 to 34 per cent, of all the cases. Infants and healthy 
adults usually recover ; in persons of feeble health, old people, 
and those vitiated by bad habits, particularly drunkards, the 
prognosis is very serious. The bearing of complications upon 
the case has been discussed ; it may be added that meningitis 
almost always proves fatal, and that abscess or gangrene of 
the lung and endocarditis are exceedingly serious. Rapid 
breathing, muttering delirium, dryness of the tongue, expector- 
ation of thin, "prune-juice" colored sputa and failing pulse in- 
dicate the approach of death. Death almost always occurs 
from heart-failure, sometimes from general poisoning, very 
rarely from thrombosis of the coronary arteries. 

Termination. — Resolution may occur promptly, all the phy- 
sical signs, save a moderate amount of dulness, disappearing 
within ten to fourteen days. In other cases it is indefinitely de- 
layed, even for a period of months, requiring unceasing care on 
part of the physician. Pulmonary abscess and gangrene may 
occur. The former is recognized by the severity of the consti- 
tutional symptoms, cavernous signs, and the sudden discharge, 
with coughing, of purulent and highly offensive matter. 
Chronic interstitial pneumonia often follows lobar pneumonia. 

Diagnosis. — The symptoms of pneumonia are so clear-cut 
that difficulties in recognizing the disease can exist in excep- 
tional cases only, and then these are of a character which 
demands for their solution exhaustive and careful study and 



1006 DISEASES OF THE RESPIRATORY ORGANS. 

highfy cultivated judgment. Thus a pneumonia may easily be 
overlooked when it occurs in an intercurrent form or in the 
course of chronic tuberculous or cardiac disease, in diabetes, 
albuminuria or cancer. In the aged and in infants the symp- 
toms are so vague that only post-mortem evidence may deter- 
mine the cause of death. Again, violent brain symptoms may 
wholly mask a pneumonia of infants or of drunkards. A mis- 
take may also be made between a pneumo^phus and a pneu- 
monia with profound constitutional poisoning quickly assum- 
ing a "typhoid" form. 

Treatment. — The patient must be kept, as quietly as possi- 
ble, in a room the temperature of which is to be maintained 
permanently at from 70° to 72° F. It is the part of wisdom 
not to allow the patient to leave his room and to move about 
the house until the temperature has been normal for a few 
days and all the exudate removed. Pain may justify the ap- 
plication of large poultices to the aifected side, and possibly 
the use of morphia ; the latter is rarely necessary, for the indi- 
cated remedy is capable of accomplishing more permanent 
good in this direction than does the morphine. Ice-bags on 
the affected side and cold water have long been popular in 
Europe, and the treatment is now recommended by American 
physicians. To lower the temperature, frequent sponging in 
tepid water is helpful ; if the temperature rises above 103.5°, 
the hot bath, at 70° F., must be employed, and repeated as 
often as necessary, with proper precautions not to have the 
patient take cold or become exhausted. Inhalation of oxygen 
relieves excessive dyspnoea and threatening asphyxia. Alco- 
holic stimulants may be exhibited when ad} T namia is marked 
and the pulse becomes weak, rapid and unsteady ; this applies 
particularly to the aged. Generally speaking, the beneficial 
effects of alcohol are exaggerated. The diet must be light, 
nourishing and of a character that will not produce flatulency. 
Milk, milk-whey, broths, beef-juice, eggs and raw scraped beef 
meet the demands of the case. Cool water, soda water or 
Apollinaris may be taken freely. 

Therapeutics. — Although writers of the dominant school 
practically affirm the utter uselessness of remedial agents, so 
far as it concerns their power to cut short the course of pneu- 
monia or to exert a modifying effect upon it, the exhibition of 



PNEUMONIA. 1007 

the indicated remedy, selected upon homoeopathic principles, 
does nevertheless cut short and modify the course of pneu- 
monia, reduce the gravity of complications, and materially 
lessen the death rate. 

In the beginning the choice lies between Aconite and Vera- 
trum viride, not only because these remedies depress the pulse, 
but because of their close homoeopathic relationship to the 
disease. — Aconite must be given during the stage of engorge- 
ment and great arterial excitement; when this stage has 
passed, it is no longer of use. In addition to its general char- 
acteristics it covers : dull pressure and weight on the chest ; 
stitches in the chest during inspiration and motion ; dry, rack- 
ing cough ; tenacious, bloody expectoration. — Veratrum 
viride (in the tincture or lx). Great arterial excitement; pulse 
hard and full ; great dyspnoea ; intense pulmonary congestion ; 
livid face ; dry, hacking cough, also with blood-streaked expec- 
toration. 

The disease having fully localized, the choice of remedies will 
probably lie between the following: Bryonia, Phosphorus, 
Sanguinaria, Iodine, Mercury, Tartar emetic, Chelido- 
npjm. — Bryonia is valuable during the stage of hepatization, 
and has here been used with brilliant success, for the better 
part of a century, by our best clinicians. It is especially useful 
when the pleura is involved. Sharp pains, better from lying 
on the affected side and from pressure and warmth ; keenly ag- 
gravated from motion, coughing and breathing. Either no 
thirst or great thirst for copious draughts of cold water. Con- 
stipation.— Phosphorus. Stage of hepatization, without the 
pleuritic symptoms of Bryonia ; especially helpful in thin, tall, 
spare persons who constitutionally meet the individuality of 
the remedy; the fever symptoms are not marked, and may 
have subsided. Great oppression of the chest. Sputa rust- 
colored. Typhoid, adynamic state.— Sanguinaria. Right lung 
affected (?). Tough, rust-colored sputa; pain in the chest not 
intense ; feels better when lying on the back ; pulse quick, feeble ; 
extreme dyspnoea. "Face and extremities cold; with circum- 
scribed redness and burning heat of the cheeks" (Raue). Mild 
inclination to typhoid state. — Iodum. Lacks the anxiety of 
Aconite and the sticking pains of Bryonia, but it has the high 
fever of both. Stage of hepatization. Involvement of the 



1008 DISEASES OF THE RESPIRATORY ORGANS. 

apices. Scrofulous diathesis. Has made an excellent clinical 
record. — Mercury. Rather loose cough; worse in the night, 
from lying on the right side. Copious sticky sweating at night, 
like night-sweat. Bilious symptoms ; jaundice. The fever is 
continuous, but not intense ; dyspnoea long-continued ; tongue 
yellow, then dry; urine scanty. Pneumonia of children. — 
Tartar emetic. Especially useful in the pneumonia of old 
people, of persons of feeble vitality ; also at the close of the 
third stage. There is considerable dyspnoea, with wheezing 
and rattling, and lack of sufficient energy to expel the bron- 
chial contents. Livid, pale face ; rapid, feeble pulse ; cool, moist 
skin. Threatening paralysis of the lungs. Drunkards. — Chel- 
idonium. Has proved of service in right-sided pneumonia, with 
symptoms of hepatic disorder, pain under the right shoulder- 
blade ; rattling in the chest, with inability to expectorate. 

If there is heart failure : Cactus, Strophanthus, Digitalis. 
Typhoid state : Baptisia, Rhus toxicodendron, Arsenicum, 
Opium, Phosphorus, Carbo vegetabilis. If dyspnoea is exces- 
sive : Grindelia robusta, Quebracho, Carbo vegetabilis. If 
resolution has commenced, but is tardy, the case becoming al- 
most chronic : Arsenicum iodatum, Calcarea iodata, Kali 
carbonicum, Kali muriaticum, Lycopodium, Silica, Sulphur. 

CHRONIC INTERSTITIAL PNEUMONIA. 

A chronic inflammation of the connective tissue framework 
of the lungs and of the walls of the air cells, resulting in a 
gradual substitution of connective tissue for the normal lung. 
The terms "local" and "diffuse" are used to designate the ex- 
tent of the area involved, the disease sometimes being re- 
stricted to a limited space, again affecting the entire lung or 
both lungs. 

./Etiology. — Localized interstitial pneumonia is almost con- 
stantly present in restricted inflammatory processes, as in 
tuberculosis, phthisis, abscesses, hydatids, gummata, or in 
limited inflammation (thickening) of the pleura. The diffuse 
form may follow, rarely, acute fibrinous pneumonia, chronic 
broncho-pneumonia, chronic pleuritis, chronic bronchitis, or 
the long-continued inhalation of the dust of coal, stone, or 
metals (pneumonokoniosis). 



CHRONIC INTERSTITIAL PNEUMONIA. 1009 

Morbid Anatomy. — Delafield gives the following: "If it fol- 
low acute lobar pneumonia with the production of new con- 
nective tissue, one lobe or one entire lung is covered with 
pleuritic adhesions; it is small, smooth, and dense; the air 
spaces and small bronchi are obliterated by the new connective 
tissue. Some of the bronchi may be dilated. If it be conse- 
quent upon broncho-pneumonia, one or more lobes are studded 
with fibrous nodules or are converted into dense fibrous tissue. 
The pleura is thickened, the bronchi are inflamed and often di- 
lated. If it be concomitant of the thickening of the pleura, 
bands of connective tissue extend from the pleura into the lung ; 
there is inflammation of the bronchi and often dilatation. If it 
follow chronic bronchitis, there are fibrous nodules around the 
bronchi, with more or less diffuse connective tissue. If it be 
due to the inhalation of the dust of coal or stone, we find in 
both lungs fibrous peribronchitic nodules and diffuse connect- 
ive tissue. In most of the cases the portions of lung exempt 
from the interstitial pneumonia are emphysematous." 

Symptoms. — The symptoms are such as belong to the patho- 
logical changes going on in the lung, and disappear when 
these have been completed, often leaving the patient in a state 
of fairly good health. More or less cough is present from the 
beginning, and increases both in severity and frequency as the 
disease advances. There is expectoration of mucus, then muco- 
pus, exceptionally fetid or tinged with blood; haemoptysis 
may occur. A certain amount of dyspnoea is felt throughout, 
noticed in some cases only when the patient ascends an eleva- 
tion; others suffer from it perpetually. When there is much 
bronchial dilatation the case presents symptoms of bronchiec- 
tasis, especially characteristic cough at long intervals with 
copious raising of muco-pus. Pain in the affected lung may 
not be complained of, but the patient loses flesh and strength. 
Fever occurs only during acute bronchial exacerbations. The 
larynx is not involved. Colliquative diarrhoea does not com- 
plicate the case. 

Physical signs consist of retraction and immobility of the 
affected side, with enlargement of the opposite side. The heart 
is displaced by the traction exerted upon it ; the shoulders be- 
come stooped, and there may be lateral spinal curvature. The 
sounds elicited by percussion vary with the extent of the bron- 
64 



1010 DISEASES OF THE RESPIRATORY ORGANS. 

chial involvement; they may be dull at the base or apex, 
tympanitic or amphoric elsewhere. Tympanitic resonance is 
usual on the unaffected side. Auscultation yields the sounds of 
various stages of bronchial inflammation, dilatation or con- 
solidation. 

The duration of the disease is chronic, and death usually 
results from heart failure or haemorrhage, rarely from amyloid 
degeneration. 

The diagnosis is comparately easy ; the presence of tubercle- 
bacilli must be established, if possible, to determine the origin 
of the disease. 

Pneumonokoniosis is due to inhalation of dust in the pursuit 
of such occupations as coal-mining (anthracosis), marble- or 
stone-cutting (chalicosis or stone-cutter's phthisis), working 
in metals, as grinding knives or scissors (siderosis and grind- 
ers' rot). Tlie lungs are studded with fibrinous peribronchitic 
nodules, from the size of a pea to that of a hazel nut, and 
larger, usually surrounded by firmly consolidated, grayish, 
crepitant tissues, a small bronchus forming the center of the 
diseased area. These may coalesce and form large, firm scir- 
rhous masses. There is chronic bronchitis with emphysema, 
with eventual softening and necrosis. The symptoms are very 
much alike, the most interesting feature of the affection con- 
sisting of the extended period, often a long series of years, of 
continuous exposure to these irritating substances with the 
enjoyment of reasonably good health. When the patient 
finally breaks down, general and rapid failure of health and 
strength is observed, with cough and muco-purulent expectora- 
tion, usually of the color of the substance which has been in- 
haled. 

The treatment of chronic interstitial pneumonia consists of 
careful attention to the diet of the patient, to his general 
health, and, if within reach, a change of climate. The choice 
of medicinal agents is guided by symptomatic indications (see 
Chronic Bronchitis). 

BRONCHO-PNEUnONIA. 

Broncho-pneumonia, lobular pneumonia, capillary bronchi- 
tis, sometimes still called catarrhal pneumonia, is an inflam- 



BRONCHO-PNEUMONIA. 1011 

mation which involves the walls of the terminal bronchi and 
of the air vesicles which surround them. 

./Etiology. — The disease is hardly ever primary, but usually 
occurs in a secondary form with measles, diphtheria, whoop- 
ing-cough, scarlet fever, and other acute infectious diseases of 
childhood, constituting one of their most dangerous complica- 
tions and sequels. In many cases it is excited by the presence 
of the bacillus tuberculosis. Cases occur (as after operations 
on the nose, mouth or larynx, or in laryngeal or oesophageal 
cancer, or as the effect of cerebral disease, such as apoplexy or 
uraemic poisoning) where there is great or complete loss of sen- 
sitiveness of the larnyx, and small particles of food are allowed 
to enter the lungs, the presence of which excites intense inflam- 
mation (deglutition pneumonia). The same effect is produced 
by the entrance into the lung of blood from a haemoptysis or 
by the aspiration of the purulent contents of a cavity in the 
lung (aspiration pneumonia). In adults the affection is com- 
paratively rare, though it may occur as a complication of 
typhoid fever ; aged persons often suffer from it in the course 
of debilitating acute or chronic diseases. Extremes of life and 
physical debility are powerful predisposing causes. Children 
of less than five years of age are especially subject to broncho- 
pneumonia, particularly those of weak constitution, suffering 
from rickets or diarrhoea, and raised among insanitary sur- 
roundings. 

Morbid Anatomy. — The lung is abnormally full and firm; the 
walls of the small bronchi and bronchioles, usually of one 
lung or of one lobe, are thickened ; the affected bronchi are sur- 
rounded by consolidated lung tissue, forming solid nodular 
bodies, rarely larger than a pea ; irregular areas of consolidated 
tissue are scattered throughout the affected lung. Areas of col- 
lapsed tissue, greatly varying in extent, and sometimes involv- 
ing a considerable portion of the lung tissue, are seen. The 
pleura often is coated with fibrin. The bronchial glands are 
usually inflamed and swollen. Upon section the lung appears 
dark-red and rich in blood. Isolated patches of affected tissue, 
of light color and usually separated by areas of sound tissue, 
project above the level of the section. Osier describes as fol- 
lows the appearance of an isolated patch of broncho-pneumonia: 
(a) A dilated central bronchiole full of tenacious, purulent 



1012 DISEASES OF THE RESPIRATORY ORGANS. 

mucus, (b) Surrounding the bronchus from 3 to 5 mm., or even 
more, is an area of grayish-red consolidation, usually elevated 
above the surface and firm to the touch. It may present a per- 
fectly smooth surface or be distinctly granular. If the disease 
is far advanced, small grayish-white points ma}' be seen, i. e., 
drops of purulent matter which may be squeezed out. A sec- 
tion in the axis of the lobule may present a somewhat grape- 
like arrangement, the stalk and the stems representing the 
bronchioles and the alveolar passages filled with yellowish or 
grayish-white pus, while surrounding them is a reddish-brown, 
hepatized tissue, (c) In the immediate neighborhood of this 
peribronchial inflammation the tissue is dark, smooth, airless, 
and sunken in (splenization), representing tissue in the early 
stage of inflammation. In some cases the nodules of consoli- 
dated tissue are grayish in color and the air cells are filled with 
a grayish, mucopurulent material. 

The affected bronchus is filled with a plug of exudation (leu- 
cocytes and swollen epithelium), the involved air cells contain- 
ing leucocytes and swollen endothelium. Various micro-organ- 
isms are present (micrococcus lanceolatus, streptococcus pyo- 
genes, bacillus pneumoniae, staphylococcus aureus et albus, 
Klebs-LoefFler bacillus). 

As stated by Delafield, the essential or constant lesions con- 
sist of the productive inflammation of the walls of the bronchi 
and of the air spaces immediately surrounding the inflamed 
bronchi; the accessory lesions are: catarrhal inflammation of the 
bronchial mucosa; an exudative inflammation of the air- 
spaces, resulting in their cavities being filled with fibrin, pus 
and epithelium, and consolidation ; exudative inflammation of 
the pleura ; dilatation of the affected bronchi ; areas of atelec- 
tasis ; inflammation (simple or tubercular) of the bronchial 
glands. 

Symptoms. — The onset of the disease is rarery sudden. Oc- 
curring in connection with acute infectious diseases, especially 
measles and whooping-cough, there is usually an increase of 
fever, sometimes preceded b} r chilliness, with cough, rapid pulse 
and quick, superficial breathing. In severe cases the symptoms 
are more pronounced, and convulsions and delirium may be 
present. The fever continues, with a temperature ranging from 
102° to 104° F. As in the bronchitis and pneumonia of chil- 



BRONCHO-PNEUMONIA. 1013 

dren, the fever often assumes a distinctly remittent type, with 
a morning temperature of 99° to 100° F., and an evening tem- 
perature which may reach 105° F. The height of the tempera- 
ture is in proportion to the intensity of the disease, and thus be- 
comes an important item in the prognosis of the case ; but it 
must be borne in mind that recovery often takes place when 
the temperature has been persistently high, while death may 
occur in cases where the fever and temperature were of moder- 
ate range. The pulse is rapid, from 120 to 160, and often be- 
comes thready ; the skin is dry and pungent. Respiration is 
rapid, shallow and unsatisfactory, ranging from 40 to 80 a 
minute. Dyspnoea is a common symptom; it is severe, pro- 
gressive, and accompanied with signs of deficient aeration of 
the blood (blueness of the finger tips). A sense of impending 
asphyxiation greatly distresses the child, until in the fatal cases 
carbonic acid poisoning affects the nerve centres. If the latter 
takes place, the respiratory effort becomes indifferent, the 
cough subsides, the patient grows livid and drowsy, the bron- 
chial tubes fill with mucus, and death results from paralysis 
of the heart. (Suffocative catarrh.) Cough is usually hard, 
sometimes painful, and due chiefly to bronchial catarrh ; expec- 
torated matter is swallowed. The face is flushed ; the tongue 
coated or dry ; the patient is sleepless and restless ; urine con- 
tains traces of albumin and casts if the kidneys are acutely in- 
volved. In very young infants it may be difficult to recognize 
the disease, since there may be an entire absence of cough and 
of physical signs, the chief symptoms consisting of more or less 
fever, prostration and quick, superficial breathing. Such cases 
may prove rapidly fatal. In other instances the cerebral symp- 
toms (convulsions, delirium, stupor) at the onset of the disease 
are so severe as to closely resemble acute or tubercular menin- 
gitis ; but they rapidly improve on the appearance of the pul- 
monary affection. 

The clinical history of broncho-pneumonia in adults differs 
from the description given chiefly in the infrequency of cerebral 
symptoms, in the prominence of catarrhal bronchitis, and in 
the resemblance of the affection to lobar pneumonia, with the 
expectoration of blood-stained, purulent matter. 

Physical Signs. — In the early stage auscultation usually 
yields fine rales at the bases of the lungs or throughout the 



1014 DISEASES OF THE RESPIRATORY ORGANS. 

lungs ; all the signs of catarrhal bronchitis may be present. If 
the broncho-pneumonia is quite limited in extent, distinctive 
signs may be almost wholly wanting ; if the pneumonia is ex- 
tensive and large areas of consolidated tissue exist, there will 
be dullness on percussion, bronchial breathing and broncho- 
phony-. Tubular breathing is especially pronounced when many 
foci are scattered over the greater part of the lobe. 

The duration and course of broncho-pneumonia vary. In the 
severe form seen among young infants, death frequently oc- 
curs within two or three days ; the greater number of fatal 
cases die within two weeks, but often the case drags along for 
six, seven or eight weeks. Usually, in favorable cases the con- 
stitutional symptoms persist for one or two weeks after the 
force of the local disease is broken, much depending on the 
vigor of the child and its constitutional bias. If recovery is 
very protracted, especially when the apices were involved, there 
is always reason to fear possible tuberculous tendency. Im- 
perfect recoveries are common. The child survives the acute at- 
tack, but a chronic, low inflammatory action persists, with 
poor appetite and loss of flesh and strength, not necessarily 
preventing an eventual recovery, but more often leaving con- 
solidation of some portion of the lung, or a chronic interstitial 
pneumonia, or affording a focus for general tuberculous infec- 
tion ; sometimes death occurs from exhaustion. Suppuration 
and gangrene frequently result in deglutition and aspiration 
pneumonia. 

Diagnosis. — Lobar pneumonia and broncho-pneumonia have 
many points of similarity, and when the latter is characterized 
by the presence of many foci or extensive consolidation involv- 
ing the greater part of one lobe, differentiation may prove very 
difficult. Broncho-pneumonia, however, usually attacks chil- 
dren during the first five years of life, while lobar pneumonia is 
more common from the fifth to the fifteenth year ; the former is 
almost always bilateral, the latter unilateral; the onset of 
broncho-pneumonia usually is gradual, that of lobar pneumo- 
nia sudden. The course also differs, lobar pneumonia termina- 
ting on the eighth or tenth day, while in broncho-pneumonia 
the duration of the disease is longer and the resolution slower. 
The character of the expectoration in broncho-pneumonia, re- 
sembling that of bronchitis, is also of value. The question often 



BRONCHO-PNEUMONIA. 1015 

arises whether a case is one of simple or of tuberculous 
broncho-pneumonia. In adults this applies to cases where the 
invasion is slow, the fever moderate, the cough persistent, with 
emaciation, weakness, nightly exacerbations and night sweats. 
A positive diagnosis here rests upon the recognition of the 
bacilli of tuberculosis. In children the existence of extensive 
involvement of the upper portions of the lung, especially of the 
apices, with tardy recovery, warrants fear of tuberculous 
disease. 

Prognosis. — The prognosis must always be guarded. If the 
disease is secondary to an acute affection, as measles or whoop- 
ing-cough, the chances are much better than when it occurs in 
infants who are exhausted by some long-continued fever or 
constitutional disease. Tough, wiry children may survive at- 
tacks which prove fatal in large, fleshy infants. There is a 
.form of broncho-pneumonia in adults, characterized by great 
suddenness of onset, rapid elevation of temperature, severe 
chest-pain, great prostration, badly embarrassed breathing, 
and symptoms pointing toward an extensive pneumonia, which 
runs a rather rapid course and often proves fatal. The prog- 
nosis in deglutition- and aspiration-pneumonia is always 
-grave. 

Treatment. — The sick-room must be kept at an even temper- 
ature (65° to 70°), and the air charged with vapor. Cold 
- water should be drunk freely. The diet must be both light and 
nourishing, and will usually consist of milk, malted milk, egg- 
albumin dissolved in water and slightly sweetened, and broths. 
If bronchitis is general, hot fomentations and poultices may be 
applied over the chest, to'be removed at short intervals and 
with due precautions to avoid taking cold ; the cotton-batting 
jacket is also useful. When cerebral symptoms are pronounced, 
the wet pack or bath in agreeably warm water, gradually re- 
duced to 80° or 76°, is far better than bromides, phenacetine or 
opium. Emetics (wine of ipecacuanha, tartar emetic) may be 
necessary if the child cannot raise the abundant accumulation 
in the tubes, but should not be used hastily or recklessly. In- 
halations of oxygen are often of service in the later stage. Al- 
coholic stimulants may be exhibited in adults, in moderate 
doses, but are absolutely useless and positively dangerous in 
young children and infants. If the recovery is tedious, cod- 



1016 DISEASES OF THE RESPIRATORY ORGANS. 

liver oil may prove beneficial ; a change of air frequently be- 
comes imperative. 

The remedies employed are those discussed under bronchitis 
and lobar pneumonia. — Tartar emetic is especially useful in 
children. 



EMPHYSEMA. 

The term "emplrysema" means a dilatation or distension with 
gas or air. Applied to the lung, emplwsenia may be interlobu- 
lar or vesicular. 

Interlobular emphysema results from the rupture of one or 
more air vesicles, forcing the air into the connective tissue be- 
tween the lobules, oftenest near the apices, and forming 
pouches of various size. The rupture is usually the result of 
a violent strain suddenly put upon the walls of the air vesicles, 
such as might arise from the sudden inspiration of a large 
amount of air and its forcible retention by the closure of the 
glottis or from a strain made in heavy lifting, defecation, during 
labor, violent paroxysms of coughing, etc. It often occurs in 
the broncho-pneumonia of young children. Recognition during 
life, from S3^mptoms or physical signs, is exceedingly difficult. 
The anatomical changes consist of inflation of the connective 
tissue septa with air, and compression of the lung tissue proper. 
Exceptionally the air, through the mediastinum, enters the con- 
nective tissue of the neck and thoracic wall. 

Vesicular emplrysema consists of dilatation of the air vesicles 
from an excess or over-accumulation of air in them. The air 
vesicles eventually coalesce, effacing the interstitial tissue and 
its blood vessels, and thus seriously interfere with the proper 
nutrition of the lung. 

(a) Compensatory emphysema results when a portion of 
the lung is compelled to do extra work because of the inca- 
pacity of some other portion to carry on its function. The 
condition, at first purely physiological, eventually becomes 
pathological. It is best seen in cirrhosis of the lung and in 
broncho-pneumonia. 

(b) Atrophic or senile emph3 T sema is a feature of senile degen- 
eration, a tropin^ of the alveolar walls resulting in enlargement 
of the air spaces. It is an expression and result of general 



EMPHYSEMA. 1017 

atrophy of the lung substance. The chest is small, the ribs are 
set obliquely, and the appearance of the patient is old and 
withered. The condition is incurable. 

(c) Hypertrophic or substantive emphysema is by far the 
most important form. Its aetiology must take cognizance of 
two factors: (1) high pressure within the air cells and (2) weak- 
ness, congenital or acquired, of the lung tissue. This pressure 
is more likely to be intensified during expiration. "In all strain- 
ing efforts and violent attacks of coughing the glottis is closed 
and the chest walls are strongly compressed by muscular ef- 
forts, so that the strain is thrown upon those parts of the 
lungs least protected, as the apices and anterior margins, in 
which we always find the emphysema most advanced. The 
sternum and costal cartilages gradually yield to the heightened 
intrathoracic pressure and are, in advanced cases, pushed for- 
ward, giving the characteristic rotundity to the thorax. The 
cartilages gradually become calcified." (Osier.) For the rea- 
sons stated, bronchitis and whooping-cough are frequently as- 
sociated with emphysema, and certain occupations, as glass- 
blowing and playing on wind-instruments, are important aetio- 
logical factors. Hereditary tendency undoubtedly exists ; Louis 
found that of twenty-eight cases carefully studied, in eighteen 
cases one or both parents had emphysema pulmonum. 

Morbid Anatomy. — Both lungs are usually increased in size, 
have a downy, feathery feel, and pit on pressure ; the thorax is 
large, barrel-shaped ; the cartilages are calcified. The dilata- 
tion of air spaces and vesicles differs in degree, and, according 
to clinical evidence, the degree of dilatation does not determine 
the severity of the emphysema. In some cases the enlarged air 
vesicles can easily be seen beneath the pleura, and, if large, may 
project from the free margins as large , irregular bullae. There 
is gradual disappearance of the capillary net work of the alve- 
olar walls, ~with atrophy ; loss of elastic tissue is an essential 
feature of the lesion. Some writers attach much importance to 
''holes" with sharp-cut edges in the walls of the air-spaces, be- 
tween the capillaries. Dilatation and hypertrophy of the right 
ventricle are common, and venous congestion in more distant 
parts (pia mater, stomach, kidneys, intestines) occurs when 
the disease is advanced. Intercurrent attack's of bronchitis are 
frequent, with occasional bronchiectasis. 



1018 DISEASES OF THE RESPIRATORY ORGANS. 

Symptoms.— Emphysema may exist for a long time without 
causing appreciable annoyance or symptoms. Dyspnoea upon 
exertion is, however, likely to be present early, and if in young 
children difficulty of breathing invariably results from run- 
ning or playing, or from any exertion, the cause should be care- 
fully investigated. In more advanced cases this symptom may 
become a source of great affliction, especially so since it is sure 
to be much intensified from recurring attacks of bronchitis and 
from indigestion. In some cases frequent and severe par- 
oxysms of asthma are a conspicuous feature. Bronchitis, in re- 
peated attacks of an acute character or in the chronic form, ac- 
companies all cases, presenting its own train of symptoms, and 
at times almost wholly overshadowing all the other symptoms. 
The influence of season upon the frequency and severity of the 
cough shows itself here as in bronchitis. Cyanosis is pro- 
nounced, and is peculiar in that it does not interfere with the 
patient's ability to be about. Attention has been called to the 
fact that in any other disease of the lungs or heart capable of 
causing the same degree of cyanosis, the patient would surety 
be in bed and suffering intensely. In due course of time the 
cardiac S3 r mptoms assume a grave aspect ; dilatation occurs ; 
exhaustion becomes marked ; the stomach, intestines, liver and 
kidneys suffer from venous congestion, and finally anasarca re- 
sults. 

Physical Signs. — Inspection yields important results. In 
light cases no changes are observed, but when advanced, a pe- 
culiar barrel-shaped appearance of the thorax is noticed, which 
depends upon a great increase of the antero-posterior over the 
lateral diameter of the chest. There is also widening of the in- 
tercostal spaces, most pronounced in the hypochondriac region. 
The clavicles are prominent ; the sternal fossa deep ; the neck 
appears shortened ; the back is rounded from an exaggeration 
of the spinal curvature. If dyspnoea is great, the muscles 
which are involved in the respiratory act are abnormally large. 
The chest itself moves but slightly, even during deep respiration. 

Palpation shows feeble vocal fremitus, distinct pulsation in 
the epigastrium, slight apex beat. Percussion 3 ? ields hyperres- 
onance, almost drum-like, tympanitic. Auscultation reveals 
feeble rales. Usually the expirator}' sound is prolonged, wheezy, 
harsh, with coarse and sibilant rales ; sometimes both inspira- 



ABSCESS OF THE LUNG. 1019 

tory and expiratory sounds are exaggerated, loud, high- 
pitched. In advanced cases there is tricuspid regurgitant mur- 
mur. 

The course of the disease is chronic, with frequent periods of 
exaggeration from attacks of bronchitis and asthma, and a de- 
cided down-hill tendency, death eventually, sometimes after 
many years, taking place from complications or from intercur- 
rent disease. 

The prognosis, except in light cases "where no structural 
changes have occurred, is unfavorable. 

Treatment must aim to improve by all means possible the 
general health of the patient, maintain digestion and assimila- 
tion, relieve the dyspnoea, control the bronchial irritation, and 
meet other emergencies as they arise. To this end a well regu- 
lated, open-air life, with an abundance of good, easily digested 
food and abstinence from alcohol, tobacco and saccharine and 
starchy foods are highly beneficial. Fats are recommended. 
Compressed air, systematically and perseveringly used, has 
proved of benefit. The bronchitis and dyspnoea must be man- 
aged according to the indications of the case. When the dysp- 
noea is caused by the contraction of the small arteries, amyl 
nitrite, nitro-glycerine, or chloral hydrate often relieve. All vio- 
lent exertion of any kind must be avoided. 

Remedies are to be selected from symptomatic indications, and 
are practically those of bronchitis and asthma, which chapters 
consult. E. M. Hale claims that Coca and Quebracho are 
the only two remedies which afford continuous relief. Of the 
former, he gives teaspoonful doses of the tincture ; of the latter, 
10 to 15 drops of the tincture or one grain of the solid extract, 
or -^ of a grain of aspidospermine. 

ABSCESS OF THE LUNG. 

Pulmonary abscess may follow pneumonia, but is rare ; it is 
frequent in deglutition and aspiration pneumonia. The ab- 
scess of lobar or lobular pneumonia is usually small and the 
character of the pus offensive, though very much less so than 
the odor of pulmonary gangrene or fetid bronchitis. This rule, 
however, has exceptions. In two cases seen within the last 
few years, both following lobar pneumonia, the abscesses were 



1020 DISEASES OF THE RESPIRATORY ORGANS. 

large and the contents horribly offensive. It is not always 
easy to recognize the formation of an abscess, for, if deep- 
seated, no reliable physical signs may be detected and the ex- 
acerbation of the general symptoms presents nothing charac- 
teristic ; the sudden raising of a considerable amount of pus, 
containing fragments of lung tissue, with the physical signs of 
a cavity remaining, clears the diagnosis. 

Metastatic or embolic pulmonary abscesses are common in 
pyaemia, as the result of infection by emboli. They are rarely 
recognized, for the local symptoms are overshadowed by those 
of the constitutional disease. They are usually superficial, near 
the pleura, at first grayish-red and firm, surrounded by an 
areola of intense redness ; the abscess is well defined, and per- 
foration, often resulting in pneumo-thorax, is likely to result. 

Other causes are chronic pulmonary tuberculosis and injuries 
of the lung-tissue from without, as from foreign bodies or from 
perforation of an abscess without (abscess of the liver perfor- 
ating into the right lung). 

The prognosis is always serious and recoveries rare, save as 
the abscess is superficial and may thus be opened and drained. 
The remedies are those symptomatically indicated, the choice 
probably lying between Arsenicum album, Chininum arsen., 
and Silica. The two cases to which reference has been made 
recovered under Arsenicum album 3x, with occasional doses 
of China 8, a generous diet, and, in one case, the generous use 
of old California Port Wine. 

GANGRENE OF THE LUNGS. 

The term "gangrene," here as elsewhere, denotes putrefaction 
or desiccation following the death of a part of the living organ- 
ism. It occurs as a sequence of lobar pneumonia, especially in 
greatly debilitated and in diabetic subjects ; as a termination of 
aspiration pneumonia, including perforation of oesophageal 
cancer into the lungs or a bronchus ; in bronchiectasis, from the 
foulness of retained secretion ; in embolism of the pulmonary 
artenr, either simple or derived from some necrosed part ; as an 
expression of great debility or cachexia. To the latter cause 
is due the comparative frequency of pulmonary gangrene in 
drunkards and lunatics and in children suffering from eruptive 



GANGRENE OF THE LUNGS. 1021 

fevers and cancrum oris. The affection may be diffuse or cir- 
cumscribed. 

Morbid Anatomy. — The affected part of the lung is of a 
dark, dirty olive or greenish-brown color and of distinctly gan- 
grenous odor. "When scattered patches of gangrene occur, 
there is often in one part a solid mass of greenish lung- tissue, 
and in another a central sloughy gangrenous cavity, sur- 
rounded by a broad rim of soft, infiltrated lung. The seat of 
circumscribed gangrene is usually the periphery of the lung and 
the lower lobes. In diffuse gangrene the whole of one lung is 
sometimes involved. The pulmonary tissue is then converted 
into a black, putrid substance, saturated with blackish, puru- 
lent fluid ; or the gangrenous part merges gradually into oede- 
matous or hepatized tissue" (E. Symes Thompson). Bronchitis 
is commonly present; pleural involvement, resulting in pyo- 
pneumothorax, occasionally occurs. There may be plugging of 
the bronchial or pulmonary arteries. 

Symptoms. — The characteristic and only reliable diagnostic 
symptom is the discharge from the gangrenous mass. It is 
horribly offensive, the fetor communicating itself to the breath 
of the patient, and rendering presence in the sick-room almost 
unendurable. This arises from communication between the 
gangrenous cavity and bronchial tube ; if no such communica- 
tion exists, as in cases of limited involvement, there is no odor, 
and the existence of the affection may not be suspected during 
life. The discharge separates into three layers: a heavy, green- 
ish-brown sediment; a thinner, darkish brown middle layer; 
and a superficial frothy top layer. Shreds of tissue, granular 
matter, fatty crystals, bacteria, pigment, blood and leptothrix 
are easily seen under the microscope. There is usually moder- 
ate fever, rapid, weak pulse, prostration, and some dyspnoea. 
The physical signs are those of a cavity and of bronchitis. 
Death usually ensues from exhaustion, sometimes from haem- 
orrhage. 

Treatment.— The efforts of the physician are largely limited 
to measures for the relief of the primary disease and to the sup- 
port of the patient's strength by nourishing diet and stimu- 
lants. Much attention must be paid to the removal of the hor- 
ribly offensive odor arising from the discharge and of the breath 
of the patient. If cuspidors are used, they must contain active 



1022 DISEASES OF THE RESPIRATORY ORGANS. 

disinfectants and are to be emptied as soon as used. Carbolic 
acid spray is to be freely used in the sick-room. The patient 
must inhale carbolic acid, thymol, myrtol, eucalyptol or tere- 
bene. If the cavity can be localized and is accessible, and other 
means have failed, surgical measures should be adopted. 

It is very difficult to determine the actual value of internal 
medication. Theoretically, there is no reason why the indi- 
cated remedy should not favorably affect a case of pulmonary 
gangrene as promptly as it is known to affect a case of gan- 
grene located elsewhere. As a matter of fact, however, reliable 
testimony to this effect is wanting. Arsenicum, Lachesis and 
Carbo vegetabilis should be carefully studied in addition to 
the remedies suggested by the symptoms of the primary disease. 

CANCER (New Growths) OF THE LUNGS. 

A disease chiefly of middle life. As a primary affection it is 
rare, is almost always unilateral, often occurring as a large 
growth occupying the greater part of one lung, and is usually 
epitheliomatous, scirrhous, encephaloid, more rarely sarcoma- 
tous or enchondromatous. Secondary cancer is more frequent, 
bilateral, sometimes solitarj- and chiefty confined to the pleura, 
occasionally disseminated, and in character encephaloid, scir- 
rhous, epitheliomatous, colloid, melano-sarcomatous, enchon- 
dromatous or osteomatous. It occurs oftener in women than 
in men. Pleuritic involvement, with sero-fibrinous or haemor- 
rhagic effusion and involvement of the tracheal, bronchial and 
cervical glands, are common. 

The symptoms frequently are vague, especially so when the 
disease is primary. There is pleuritic pain, d} r spncea from pres- 
sure chiefly upon the trachea, and dry, painful cough, with thin, 
dark-colored expectoration, somewhat resembling prune juice, 
and so designated. The development of the growth tends to 
encroachment upon other organs and to the appearance of 
important sjmiptoms due to compression. Thus, compression 
of the trachea and bronchi gives rise to embarrassed breathing ; 
of the veins, to marked lividit}^ of the face and arms ; the heart 
may be pushed toward the unaffected side, and distressing em- 
barrassment of the respiration and of the heart's action be 
caused if the pneumo-gastric and recurrent laryngeal nerves 



DISEASES OF THE PLEURA. 1023 

are caught in the meshes of the new growth. The physical 
signs are not characteristic, save those denoting consolidation 
of tissue. It is stated that the patient prefers to lie on the 
affected side. The course of the disease is from six to ten 
months, though death may occur earlier. 

The diagnosis of primary cancer is difficult and sometimes 
impossible ; it usually rests upon the unilateral character of the 
affection and the existence of such symptoms as cough with 
"prune juice" expectoration, involvement of cervical (possibly 
lingual) glands, progressive emaciation, etc. The secondary 
form is more easily recognized, and in the greater number of 
cases a diagnosis can be made from the history of the case, as 
the existence of malignant disease in some other part of the 
body (uterus, rectum, liver) or the appearance of pulmonary 
symptoms after an operation for the removal of cancerous 
growths elsewhere (mammary). 

The treatment is practically restricted to efforts calculated to 
render the patient comfortable, to sustain his strength, and to 
meet emergencies as they arise. Of the remedies most likely to 
be suggested by the totality of the symptoms, the most prom- 
ising are Arsenicum, Aurum, Conium, Carbo vegetabilis. 



DISEASES OF THE PLEURA. 

Pleurisy or pleuritis, inflammation of the pleura, may be 
acute or chronic, circumscribed or diffused, primary or second- 
ary, dry or accompanied with effusion. The qualifying terms 
"tuberculous," "cancerous," etc., refer to special getiological 
factors. 

ACUTE PLEURISY. 

Acute pleurisy naturally divides itself into two distinctive 
forms: (a) dry (plastic, fibrinous pleurisy, i. e., pleuritis sicca)] 
(b) pleurisy with effusion {pleuritis humida). Since material 
differences exist in the character of the effusion and in the clin- 
ical history of each, pleurisy with effusion is divided into: sero- 
fibrinous pleurisy; purulent pleurisy or empyaema; haemorrhagic 
pleurisy. 



1024 DISEASES OF THE RESPIRATORY ORGANS. 

Dry (plastic or fibrinous) Pleurisy.— It occurs rarely as a pri- 
ma^ disease; in healtlw persons from exposure or cold, occa- 
sionally from contusion of the chest. As a secondary affection 
it is seen in nearly all forms of pulmonary inflammation, except 
those which are deep-seated. Thus it is common in pneumonia, 
tuberculous disease of the lung, cancer, abscess, etc. The in- 
jected pleura is on the surface rendered dull and lustreless from 
a covering of lymph, which varies in thickness ; if abundant, 
the friction of the opposing surfaces gives to it a flaky, shaggy 
appearance, or the fibrin arranges itself in distinct layers. Ad- 
hesions are frequent. 

The symptoms are: sudden onset with moderate fever, pain 
in the side, aggravated by deep inspiration, and dr}% rather 
painful, cough. The affection runs a brief course, the symp- 
toms yielding shortly, and recovery taking place in a few days. 
Auscultation yields friction sounds and corresponding pleural 
fremitus upon palpation. The friction sounds may remain for 
some time after all other s^mxptoms have yielded. 

The diagnosis depends upon the stitching pain in the side, 
worse from deep inspiration, and the easily recognized friction 
sounds. 

Treatment consists of rest in bed, the application of mustard 
plasters, hot poultices or turpentine stupes over the affected 
parts, and, if the pain is severe, of overlapping strips of adhe- 
sive plaster, such as are used in the treatment of fractures of 
the ribs. For "therapeutic hints" see below. 

Pleurisy with Effusion. — The essential feature of this form is 
the presence in the exudate of a considerable amount of serum ; 
the exudate may be purulent or, more rarely, haemorrhagic. 

Sero- Fibrinous Pleurisy. — ./Etiology. — It occurs chiefly in 
the cold, changeable weather of winter and spring, and princi- 
pally in adult life, oftener in men than in women. The primary 
form results from exposure, sudden wetting or chilling, or from 
an injury to the chest. Secondary pleurisy' is more frequent ; it 
is a feature of many acute or chronic pulmonary affections, 
among which tuberculous affections hold a prominent place. 
It is also seen in connection with inflammation of the pericar- 
dium and peritonaeum, more rarely in acute infectious diseases, 
as influenza and t3'phoid fever, and in acute rheumatism, gout, 
etc. 



ACUTE PLEURISY. 1025 

Morbid Anatomy. — The effusion varies from a few ounces to 
eight pints, or even more ; in an adult no disturbance results 
■when it is less than ten ounces. It closely resembles blood- 
serum. Fibrin is found on the surface of the pleura, in floccu- 
lent masses or threads floating in the exudation, or in soft 
creamy deposits in the dependent parts of the fluid ; fibrinous 
deposit may occur in the interlobar spaces and give rise to ad- 
hesion. The effusion naturally gravitates to dependent parts, 
unless it is retained by previously formed adhesions ; in excep- 
tional cases sacs are formed by the stretching of recent adhe- 
sions in which the fluid is retained (multilocular pleural effu- 
sions). It is clear or turbid, and in color varies from a light 
yellow (lemon-colored) to a darkish-brown. It also contains 
leucocytes, red blood corpuscles, swollen cells from the pleural 
epithelium, and often sufficient albumin to coagulate spontane- 
ously upon standing; sugar, uric acid and cholesterine may be 
present in small amounts. Its specific gravity is 1015 to 1023. 
The presence of a large amount of fluid in the pleural cavities 
necessarily affects the lungs. The portion of the lung above 
the level of the effusion becomes atelectatic ; if the effusion rises 
high, up to the clavicle, the lung is pressed close to the spine, 
and eventually becomes airless and even bloodless (carnified). 
Displacement of the adjacent organs follows a large effusion. 
If on the right side, there is depression of the liver, and in some 
cases change in the position of the heart ; the latter more often 
assumes a transverse position, -with some lifting of the apex; if 
on the left side, the stomach and transverse colon, and at times 
the spleen, are displaced downward. The presence of firm ad- 
hesions or of tumors and other growths in the thoracic or ab- 
dominal cavity modify the character and extent of an existing 
displacement. 

Symptoms. — The disease may approach insidiously, with 
shivering and general indisposition for several days, or its on- 
set may be sudden, with a hard chill, followed by fever and 
pain in the side, somewhat resembling pneumonia, but much 
less violent. The temperature ranges from 102° to 103°, very 
rarely beyond 104°; morning remissions are slight ; this is likely 
to continue for a week or ten days, when the temperature 
drops to normal, without, however, material change for the 
better in the patient's general condition ; in other cases a mod- 
65 



1026 DISEASES OF THE RESPIRATORY ORGANS. 

erately high temperature is maintained for several weeks. The 
temperature on the affected side may exceed that of the sound 
side by one or two degrees. The pain is sharp, lancinating, 
stitching ("stitch in the side"), and is usually limited to a 
small space in the axillary region or about the nipple ; it is ag- 
gravated b} r coughing, breathing, sneezing, violent motion of 
am^ kind, and pressure. Sometimes it is diffuse, and may be 
felt below the clavicle or scapula, or it may be retrosternal, or 
be felt in the abdomen, or, if the diaphragm is involved, in the 
small of the back, resembling lumbago. Upon the appearance 
of the effusion the severity of the pain is much lessened. Cough 
in the greater number of cases is an early symptom, though it 
may be absent. It is short, dry, painful, disappears with the 
effusion, and is liable to occur when resorption of the effusion 
takes place. It is followed by slight, mucous, sometimes blood- 
streaked, expectoration. Respiration is frequent and shallow. 
Dyspnoea is often a prominent symptom, especially in case of 
primary pleurisy in strong, rugged persons, with rapidly pro- 
gressing and copious effusion ; if the effusion takes place 
slowly, especially in feeble persons, it ma}' be very great and 
yet cause slight embarrassment of breathing, save upon exer- 
tion. The pulse is rapid, and in exceptionally severe cases ir- 
regular in force and rhythm. The position of the patient in 
bed at first is usually on the sound side ; after effusion, tying 
upon the affected side is commonly preferred. The urine is 
dark, scanty and of high specific gravity ; loss of strength and 
flesh and anaemia are present in tedious cases. 

Physical Signs. — Inspection shows increase in the frequency of 
the respiratory movement, keeping step with the extent of the 
effusion, the respiratory movement almost ceasing in very bad 
cases ; the respiratory embarrassment gives rise to dj^spncea. 
There is increase in the volume of the affected side as the fluid 
in the pleural sac accumulates, but careful measurement shows 
this increase is less than it appears to be. If the effusion is very- 
large, the intercostal spaces widen and eventually are obliter- 
ated, but very rarely bulge. If the pleurisy is right-sided, the 
apex beat is lifted to the fourth interspace or pushed beyond 
the left nipple; if left-sided, the heart-impulse cannot always be 
detected ; in cases of very extensive effusion it may be seen in 
the third or fourth spaces on the right side. After resorption 



ACUTE PLEURISY. 1027 

of the effusion, retraction and deformity of the chest are often 
observed, with displacement of adjacent organs toward the 
affected side, which in children and young subjects may be tran- 
sient, but permanent in adults. "The chest assumes an exag- 
gerated modification of the expiratory type. Its volume is di- 
minished, its antero-posterior diameter greatly decreased ; the 
lower intercostal spaces are narrowed until the ribs are in con- 
tact ; the shoulder is lowered ; the nipple sinks and approaches 
the median line, and the inner border of the scapula stands out 
from the surface of the chest" (Wilson). Lateral curvature of 
the spine, the concavity looking toward the affected side, is not 
uncommon, and a central cup-like depression in the region of 
the ensiform cartilage is occasionally seen. Palpation. Prior 
to effusion, there is pleural fremitus corresponding to the fric- 
tion sound found upon auscultation. Fluctuation is rarely ob- 
tained. Tactile fremitus is much lessened or abolished, but re- 
turns upon resorption. An important sign is the absence of 
voice vibrations ; the latter, however, may be distinct when 
communicated to the chest w all by extensive pleural adhesions. 
Mensuration. There is a difference of one to one and one-half 
inches between the sides, if the effusion is extensive. It must be 
remembered that in right-handed persons the right side is larger 
than the left. When retraction has taken place, the measurement 
changes correspondingly ; the diameters are shortened, the cir- 
cumference lessened, and the outlines of the affected side are 
those of exaggerated expiratory position. Percussion. No 
signs are obtained until the effusion reaches at least one pint. 
There is loss of resonance, first at the base posteriorly, grad- 
ually increasing with the increase of effusion until absolute dul- 
ness is reached ; this dulness is described as possessing a pecu- 
liarly resistant, wooden quality, unlike that of pneumonia. If 
the effusion is moderate, "the phenomenon of movable dulness 
may be obtained by marking carefully, in the sitting posture, 
the upper limit in the mammary region, and then in the recum- 
bent posture, noting the change in height of dulness." If the 
right side is affected, the dulness passes without change into 
that of the liver, and if the effusion is excessive, the dulness 
may not only involve the entire affected side, reaching up to 
the clavicle, but extend beyond the sternum to the other side. 
If the patient is erect, the upper line of dulnessis higher behind 



1028 DISEASES OF THE RESPIRATORY ORGANS. 

than in front. "Skoda's resonance," a very important sign, 
consists of a tympanitic sound in the subclavicular region, 
above the line of dulness, assuming a "flat" note in the lower 
mammary and axillary regions. Auscultation. Prior to the 
occurrence of effusion there is a distinct, creaking friction 
sound, much like the crepitus of pneumonia, which disappears 
as effusion takes place. It recurs after resorption, from re- 
newed apposition of the pleural laj^ers. There is feeble and dis- 
tant breathing, later broncho-vesicular, and finally bronchial, 
often accompanied with loud, coarse rales, suggesting the exist- 
ence of a cavity. Above the line of dulness the respiratory 
sounds are usualry harsh. Vocal resonance is usually dimin- 
ished or absent ; sometimes there is bronchophony^ and occa- 
sionally aegophony. If the effusion is very large, the breath- 
sounds wholly disappear and vocal resonance is lost ; Baccelli 
has pointed out the fact that the whispered voice is sometimes 
distinctly transmitted through a serous effusion, but not 
through pus. 

Course and Termination. In the greater number of cases the 
temperature becomes normal in seven to ten days, the cough 
and pain having grown less troublesome with the appearance 
of the effusion. The natural tendency is to resorption of the 
effusion, which, if small, is accomplished in a few days, but, if 
large, may consume weeks and even months. In other cases, 
notabry in tuberculous subjects, the effusion may not only per- 
sist for a long time without undergoing any change, but may 
reappear after aspiration. The effusion may assume a puru- 
lent character. Adhesions form during resorption ; these are at- 
tended with pain upon breathing and exertion, but after a time 
cease to give inconvenience. DeformhVy of the chest frequently 
results. Recovery is the rule in uncomplicated cases, but death 
has occurred suddenly, following syncope from slight exertion, 
even when the effusion was moderate. 

Treatment. — Rest in bed and nourishing, liquid diet must be 
ordered at once. If there is much pain, adhesive straps, carried 
well beyond the middle line, may be applied. After the appear- 
ance of exudation, slight counter-irritation may prove useful; 
for this purpose iodine is applied morning and evening over a 
small area, which is changed as soon as active irritation of the 
skin has been established ; mustard-plasters answer the same 



ACUTE PLEURISY. 1029 

purpose. The use of liquids should now be restricted to about 
ten ounces daily, and, in the absence of indications to the con- 
trary, a diet of meat, eggs and bread be instituted. To retard 
the effusion, it is advised also to give the patient a daily hot 
bath or vapor bath and to employ such means as will stimu- 
late the activity of the skin and kidneys. Matthew Haye's 
plan is generally adopted ; he gives to the patient every morn- 
ing, or in less rugged persons every other morning, a dose of 
Epsom salts, an hour before breakfast, from one-half to one 
ounce, as concentrated as possible. Osier states that he has 
seen large effusions disappear rapidly under this treatment. 
Aspiration must be performed if the effusion is extensive, reach- 
ing up to the clavicle, or in the presence of pericarditis, valvular 
disease of the heart or pneumonia, or if the symptoms point 
toward the development of purulent pleurisy. Fever is not a 
counter-indication. The operation is made with an aspirating 
needle of medium size, introduced in the seventh interspace in 
mid-axilla or in the eighth interspace at the outer angle of the 
scapula. The arm of the patient must be brought forward, his 
hand resting on the opposite shoulder, and he must be sup- 
ported by an assistant. The needle is thrust in quickly, giving 
it a slight upward direction, close to the upper margin of the 
rib. The fluid must be withdrawn slowly, and the operation 
stopped at once if there is faintness. A small glass of wine, or 
some other light stimulant, may be administered during the 
operation. A violent cough sometimes appears toward the 
close of the operation, but need excite no alarm. The needle 
is withdrawn quickly, and the puncture covered with adhesive 
plaster. The amount which may safely be withdrawn varies ; 
if one entire side of the chest is filled, a quart is within the 
limits of safety. It is admitted that death occasionally occurs 
during the operation; the concensus of opinion, however, is 
that the risk of a fatal termination is much greater if no oper- 
ative relief is given. 

Purulent Pleurisy— Empyema. — This form is much more fre- 
quent during the first five years of life than at any subsequent 
period ; the statement is made that in nearly one-third of all 
cases of pleuritic effusion in children it is distinctly purulent. 
Empyema may follow a Sero-fibrinous pleurisy, the effusion 
gradually becoming more and more turbid, and finally chang- 



1030 DISEASES OF THE RESPIRATORY ORGANS. 

ing into pus, probably because of pyogenic infection through 
the chest wall or within. The impression formerly held that 
aspirating causes a tendency to change the nature of the effusion 
from a sero-fibrinous to a purulent character is probably incor- 
rect, except when surgical cleanliness was not observed. A re- 
markable tendency to purulency is seen in the cases of pleuritis 
which follow scarlet and typhoid fever ; it is much less pro- 
nounced in other infectious diseases and in pneumonia and tu- 
berculous pleuritis. Local injuries, as fracture of ribs, punc- 
tured wounds, perforation of the pleura from tuberculous cav- 
ities, or the presence of malignant disease in the oesophagus and 
lungs, are fruitful causes. 

Morbid Anatomy.— The pleura is found thickened, often with 
erosions on the costal layer; fistulous openings and perfora- 
tions are common. The effusion itself varies from a slightly 
turbid exudation containing traces of fibrin to a thick, creamy 
pus. It separates into two layers: an upper, comparatively 
clear, greenish-3 r ellow serous layer, and a lower layer of thick, 
creamy pus. It is usually of a disagreeable sweet odor; offen- 
sive, when the empyema is due to traumatism ; horribly offen- 
sive when there is gangrene of the lung or of its covering. The 
organisms most frequently encountered are the streptococcus 
staphylococcus, pneumococcus, diplococcus and tubercle ba- 
cillus. 

Symptoms. — The symptoms are those of a sero-fibrinous 
pleurisy, abrupt in onset when resulting from some injur}', de- 
veloping insidiously when occurring as a secondary disease. 
Pain, cough, and dyspnoea do not essentially differ from the 
sero-fibrinous form. The symptoms which indicate pus-forma- 
tion are the appearance of fever or, if fever existed already, an 
increase of fever, assuming a remittent type. The general con- 
dition of the patient changes for the worse. There is complete 
loss of appetite, sleeplessness, restlessness, pallor, increasing 
weakness ; children suffer especially from the latter symptoms. 

The physical signs are those of pleuritis with effusion, with a 
much .greater difference in the relative size of the sides and ob- 
literation and even bulging of the intercostal spaces. Baccelli's 
sign (whispered pectoriloquy) is not heard here. There is 
oedema of the chest-walls, great prominence of the subcutane- 
ous veins, and very pronounced displacement of the liver and 



ACUTE PLEURISY. 1031 

heart. The breath-sounds, in children, are distinct and tubular. 
In some instances the impulse of the heart-beat is so forcible 
that it gives rise to a distinct pulsation (pulsating pleurisy) , 
which may be intrapleural or external, the latter in the external 
tumor of empyema necessitatis. It is perfectly proper to con- 
sider empyema in the light of a large internal abscess, the con- 
tents of which are more than usually "erosive" and "eat" their 
way out. Thus perforation is brought about, either of the 
lungs or of the wall of the chest. The former process usually 
takes place gradually, and is followed by recovery ; in fact, dis- 
charge of the pus through the bronchial tubes is always desira- 
ble unless the bronchi are suddenly inundated, in which case the 
termination is almost always rapidly fatal. Perforation of the 
wall of the chest (empyema necessitatis) is most likely to occur 
at the thinnest place, near the sternum, from the third to the 
sixth interspace. A subcutaneous abscess is formed, with red- 
ness and oedema, discharging through one large or several 
smaller openings. Fistulous communications may open into 
the pleura at some considerable distance from the external 
orifice, -with an oblique, irregular track, allowing only slow dis- 
charge of the contents ; these may exist for years. Perforation 
may also take place into the pericardium, oesophagus, stomach 
or peritonaeum ; the pus has even been known to work its way 
downward along the spine, following the psoas muscle, into 
the iliac fossa, closely resembling a psoas or lumbar abscess. 
In other cases, when the purulent accumulation is not large, 
absorption may take place ; the chest wall sinks in, the pleural 
layers become thickened, inspissated pus is retained, and lime 
salts may form. The sputum contains crystals of leucin and 
tyrosin. 

The course of the disease is tedious and the prognosis bad, 
save in children, who more readily recover, even without surgi- 
cal interference. 

The treatment, aside from careful attention to diet and 
measures calculated to sustain the strength of the patient, is 
chiefly surgical. While the patient is doing well, especially in 
children, it is usually safe to trust to the recuperative power of 
nature and to remedies ; but should the pulse become irregular 
and weak, respiration embarrassed, and the patient's general 
appearance unsatisfactory, the pus cavity should be promptly 



1032 DISEASES OF THE RESPIRATORY ORGANS. 

emptied by the use of a large aspirator needle or, far better, by- 
free incision, with the establishment of free drainage. In the 
latter case, after-treatment by distension of the lung on the 
affected side is an important consideration in securing the clos- 
ing of the cavity. Osier highly recommends for this purpose 
Ralston James' method. "The patient daily for a certain 
length of time, increasing gradually with the increase of his 
strength, transfers by air pressure water from one bottle to 
another. The bottles should be large, holding at least one gal- 
lon each, and by the arrangement of tubes, as in the Woulff s 
bottle, an expiratory effort of the patient forces the water 
from one bottle to the other. In this way expansion of the 
compressed lung is systematically practised." 

Hemorrhagic pleurisy is characterized by an amount of 
blood in the effusion which is recognized b}' the naked eye. It 
must be distinguished from hemothorax, which results from 
injury to am^ of the larger intra-thoracic blood vessels, rupture 
of an aneurism, or pressure of a tumor on the thoracic vein. 
Hemorrhagic pleurisy occurs in connection with malignant in- 
fectious diseases, in cirrhosis of the liver and affections charac- 
terized by great depression of the vital energy (cancer, Bright's 
disease, etc.); the vascularity of tuberculous new formations 
may give rise to blood in the effusion ; it is not unusual in pri- 
mary and seconda^ cancer. It may be of traumatic origin, 
as from a wound in the lung accidentally inflicted by the needle 
of the aspirator. Blood is also seen in the exudate if paracen- 
tesis of the thorax is too prolonged. Occasionally it is found in 
perfectly healthy persons. 

Other forms, as tuberculous, diaphragmatic, encysted and 
interlobar pleurisy, are recognized and have been incidentally 
mentioned. The tuberculous form is common in acute, suba- 
cute and chronic tuberculous processes, and presents the signs 
of pleurisy with sero-fibrinous effusion. Diaphragmatic pleurisy 
is limited chiefly or entirely to the surface of the diaphragm. 
It may be dry or moist, with sero-fibrinous or purulent exuda- 
tion ; commonly the exudate is plastic. The chief distinctive 
feature of this form is the loealit}' of the pain, which is so low 
as to suggest acute abdominal disease, the fixation of the dia- 
phragm, and the severity of the objective sjonptoms. Encysted 
pleurisy, formed by adhesions, is comparatively frequent in 



CHRONIC PLEURISY. 1033 

empyema. Diagnosis is difficult. Interlobar pleurisy depends 
upon agglutination of the interlobar serous surfaces, "with en- 
cysted fluid between them ; if purulent, perforation of the 
bronchi may take place. 

Diagnosis of Pleurisy. — Pleurisy is most likely to be mistaken 
for pneumonia, which it resembles in its dyspnoea, dulness on 
percussion and the usually unilateral character of the affec- 
tion. The fever of pleurisy, however, is both irregular and 
moderate, while that of pneumonia is high and characteristic, 
with evening exacerbations, morning remissions and rapid de- 
fervescence when the force of the disease is broken. In pleurisy, 
there is characteristic sharp pain, friction sound, dry cough ; in 
pneumonia pain is dull, there are crepitant rales, and expectora- 
tion. In pleurisy, usually, there is dulness, weak or absent respi- 
ration, voice and fremitus ; in pneumonia, dulness, with bron- 
chial respiration, increased vocal fremitus, thoracic voice. In 
pleurisy, effusion results in enlargement of the affected side, ob- 
literation of the intercostal spaces, sometimes bulging (em- 
pyema), and displacement of adjacent organs ; all these are ab- 
sent in pneumonia, which, however, has the characteristic rusty- 
colored sputum. 

The pain of pleurisy resembles that of pleurodynia, but the 
absence of friction sound and of fever, the shifting character of 
the pain, which often is bilateral, and the much greater exter- 
nal tenderness of the chest in pleurodynia makes the differentia- 
tion easy. Intercostal neuralgia lacks the friction sound and 
the fever, is intermittent, and presents tenderness to touch at 
the painful spots of Valleix, i. e., at the exit of the nerve from 
the spinal column, in the axillary region, and at a point near 
the sternum or in the epigastric region. 

CHRONIC PLEURISY. 

Chronic pleurisy may be dry or with effusion. Chronic pleu- 
risy with effusion may develop insidiously or follow acute sero- 
fibrinous pleurisy; the effusion itself may be sero-fibrinous, 
sometimes existing for months without undergoing changes, or 
it may be purulent, i. e. a chronic empyema 

Chronic dry pleurisy is clinically the much more important 
form. It occurs as a natural sequel of pleural effusion or as a 



1034 DISEASES OF THE RESPIRATORY ORGANS. 

primitive affection. In the former, gradual absorption of the 
effusion takes place, the pleural layers are brought together and 
become agglutinated by the fibrinous material deposited upon 
their surfaces, resulting in the organization of a thick layer of 
firm connective tissue. Small cysts containing clear fluid or in- 
spissated pus and calcifications frequently occur. These 
changes are oftener seen at the base, and cause flattening of the 
chest, insufficient expansion, and diminished respiratory mur- 
murs. They are especially marked after empyema, and partic- 
ularly in cases with perforation followed by gradual absorp- 
tion or discharge of the pus, with pronounced retraction of the 
chest on the injured side and carnification of the lung. As has 
been pointed out, the permanent mischief arising from this con- 
dition is not as great as would appear at first glance ; such 
pain as usually is felt at first gradually disappears, and perma- 
nent severe embarrassment of breathing is hardly ever experi- 
enced. Systematic expansion of the lungs, i. e., chest gymnas- 
tics, are of the greatest benefit in these cases. Primitive dry- 
pleurisy may follow an ordinary acute plastic pleurisy or may 
develop insidiously, without any acute symptoms, the appear- 
ance of friction sounds being the first indication of trouble. In 
this form there is fibrinous adhesion, but there is neither in- 
volvement of the connective-tissue frame-work nor of the lung 
tissue proper, nor deformity of the chest. Adhesions are very- 
common, especially in cases of pneumonia, and vary greatly in 
extent, involving now a small patch of the pleural surface, then 
being practically universal. No distinctly characteristic phys- 
ical signs result; extensive and firm adhesions, however, inter- 
fere more or less with freedom of respiration ; but even total 
adhesions may give rise to comparatively trifling annoyance. 
Another form of dry pleurisy is of tuberculous origin. It is of 
frequent occurrence, usually most pronounced at the apices, but 
may be universal, involving both pleurae. The pleural layers 
are greatly thickened, and are the seat of tuberculous deposits 
in varying stages of development. Retraction of the chest-wall 
is common here. Some clinicians recognize a third form of dry 
pleurisy^, followed by great thickening of the pleura, with ulti- 
mate invasion of the lung (cirrhosis). It is a disease of middle 
age, insidious in its onset, unilateral, and characterized chiefly 
bv persistent pain at the base, gradually extending friction 



CHRONIC PLEURISY. 1035 

sounds, dyspnoea upon exertion, impaired resonance at the 
base, feebleness of respiratory sounds, restriction of respiratory 
movements, and progressive retraction of the side. The disease 
is intensely chronic, and may exist for many years without ap- 
preciably affecting the general health. Bronchitis and bronchi- 
ectasis are common in the advanced stage of the affection. It 
is probable that this form is really of tuberculous character. 

Therapeutics of Pleurisy. — Aconite is useful in the first 
stage, before the inflammation has localized itself; the well- 
known characteristics are present. — Bryonia is the most im- 
portant and reliable remedy. It has sharp, stitching, "pleu- 
ritic" pain, aggravated from the slightest motion or pressure; 
dry, hard cough, with soreness in the chest wall and chest ; re- 
lief of pain from lying on the affected side ; copious sweating, 
thirst. Clinical experience proves its usefulness in all forms of 
acute and chronic pleurisy, whether dry or accompanied with 
effusion. — Apis is of value when there is extensive effusion ; the 
patient suffers much from faintness, the result of the large ac- 
cumulation of fluid in the chest. — Arsenicum, like Apis, should 
be studied -when there is effusion ; it is of service in grave cases, 
"with dread of suffocation, very scanty expectoration, great 
prostration, characteristic restlessness, and anguish. Tooker 
speaks of it as the prince of remedies in empyema. — Asclepias 
tuberosa has sharp pleuritic pain in the right side ; dry, hack- 
ing cough, with tendency to hot sweating. It is of value in the 
tuberculous chronic form. — Belladonna is occasionally indi- 
cated in children, when the case is of the strongly pronounced 
congestive type; diaphragmatic pleurisy. — Cantharides 'is 
strongly advocated by Jousset. In the exudative stage, with 
characteristic burning sensation. Slight fever ; shooting pains 
in the chest ; dry, hacking cough ; faintness, dyspnoea. — Digi- 
talis may be demanded when there is effusion with character- 
istic heart symptoms. Highly recommended by the older Ger- 
man clinicians, many of whom rank it with Bryonia. — Hepar 
sulphur, is undoubtedly a valuable remedy in the late stage of 
pleurisy and in chronic cases with purulency and such compli- 
cations as arise in connection with the process of absorption. 
Hectic fever ; chilliness ; sensitiveness to damp air. — Kali car- 
bonicum. Severe stitching pains, resembling Bryonia, but re- 
fusing to yield to it. Important in old pleuritic adhesions of 



1036 DISEASES OF THE RESPIRATORY ORGANS. 

tuberculous cases. — Mercurius. "Occasionally useful in 
chronic pleurisy, with sharp, sticking pains in chest ; aggrava- 
tion at night and from lying on the right side will characterize 
it" (T. F. Allen). Persistent chilliness, with periods of hot fever 
and fetid sweating. — Ranunculus bulb. Involvement of the 
diaphragm ; nwalgic pains in the chest ; pain as from subcuta- 
neous ulceration ; acute stabbing pains, with effusion of serum ; 
often relieves the pain of pleuritic adhesions. — Senega to a cer- 
tain extent resembles Bryonia, and has been successfully used 
when Bryonia, in cases with effusion, is indicated and has ceased 
to act. — Souilla marit. is held in high esteem by Schwabe and 
other German practitioners, who believe that it is "extraordi- 
narily useful" in bringing about rapid resorption of the exuda- 
tion. Hale prefers it to Cantharides, especially in the pleurisy 
of children. "I consider it useful when the pleuritic effusion is 
attended with capillary bronchitis caused by exposure to cold 
or dampness after eruptive fevers. The effusion is serous and 
forms rapidly, while the kidneys are very torpid and the heart 
rapidry failing in force." Sulphur, Iodine, Phosphorus, 
Silica, China and Psorinum should also be consulted. 

HYDROTHORAX. 

Hydrothorax is a dropsy of one or both pleural cavities 
without pleural inflammation. The effusion consists of a clear, 
limpid, watery fluid, without fibrin, and, although usually 
moderate in amount, it may reach several quarts. It is almost 
always secondary, occurring in connection with general 
dropsy, particularly dropsy resulting from renal or cardiac dis- 
ease ; it is due to the latter fact that the sudden occurrence of 
dyspnoea in renal and cardiac affections without general 
dropsy should at once direct attention to the pleura. In the 
majority of cases Irydrothorax is bilateral; in disease of the 
heart it oftener involves one side only. 

The physical signs are those of pleural effusion. 

The symptoms consist of great embarrassment of respiration 
when the effusion takes place suddenly and is copious ; other- 
wise its presence is hardly noticed. It is differentiated from 
the effusion of pleurisy by the absence of fever and pain, the 
presence of general dropS3% at least oedema of the feet, and the 



PNEUMOTHORAX. 1037 

existence of organic disease of the heart, kidneys, liver, or great 
vessels. Hydrothorax constitutes a dangerous complication of 
other affections and renders their prognosis very serious. 

The treatment consists of the use of saline purges and, better, 
of the aspirator. If the effusion is extensive, too much reliance 
should not be placed on remedies. Those most worthy of con- 
fidence are: Apis, Arsenicum, Digitalis, Jaborandi, Elaterium. 

PNEUMOTHORAX. 

Cases of pneumothorax, i. e., air in the lung, without the 
presence at the same time of either serous fluid (hydro-pneumo- 
thorax) or pus (pyo-pneumothorax) are rare. 

/Etiology. — The affection is one of adult life, chiefly of men, 
but may occur in infancy. In the majority of cases it is the re- 
sult of perforation due to disease of the pulmonary tissue, as in 
tuberculosis ; it is stated that 90 per cent, of all cases occur in 
connection with tuberculous disease, from the rupture of the 
wall of a cavity or necrosis of the pleura during the process of 
caseation. A similar condition is seen in septic broncho-pneu- 
monia and gangrene; or perforation of the lung may occur 
through the pleura in empyema ; or, in a sound person rupture 
of air vesicles may take place from straining. Perforation of 
the parietal pleura, resulting in pneumothorax, occurs from per- 
forating wounds of the chest (as occasionally from puncture 
with hypodermic needle) or from perforation through the dia- 
phragm (malignant disease of the stomach or colon, rarely 
from abscess of the liver). Cancer of the oesophagus may give 
rise to perforation of the pleura and pneumothorax. 

Symptoms.— The onset may be insidious and the symptoms 
so slight as not to be noticed during life. Usually, however, the 
onset is sudden, in the greater number of instances following a 
violent effort by which much stress is thrown upon the lungs, 
such as a severe fit of coughing or vomiting. There is felt a 
sensation as though something had torn or given away in the 
chest, with sharp pain in the upper part of the chest or in the 
back. If the injury is severe, and a large amount of air has 
suddenly entered the cavity, intense dyspnoea quickly follows 
("air-hunger"), with symptoms of shock, such as pallor, 
lividity, coldness of the extremities and rapid, weak pulse. 



1038 DISEASES OF THE RESPIRATORY ORGANS. 

More or less dyspnoea is present in all cases ; but it varies 
greatly in degree ; in cases of insidious growth and moderate 
extent it may amount to only inconsiderable shortness of 
breath, there being enough sound lung tissue to maintain res- 
piration. The volume of voice is lessened in proportion to the 
shortness of breath, aphonia constituting a common symptom 
of pneumothorax. Wilson Fox points out that "air-hunger'* 
is less pronounced in anaemics (pulmonary tuberculosis) because 
in such cases the blood less imperatively demands oxygen. 

Physical Signs. — Inspection : Bulging of the affected side, 
with obliteration of the intercostal spaces and, usually, dis- 
placement of the apex beat of the heart. Displacement of the 
heart and liver. — Palpation. Vocal fremitus diminished or ab- 
sent. — Percussion. The sounds obtained depend largely upon 
the extent of intrapleural tension. There is usually dulness 
over the fluid, and tympanitic or amphoric sound above. 
Change in the patient's position, bj^ changing the level of the 
fluid in the chest, renders the dulness movable. — Auscultation. 
Absence of breath-sounds on the affected side, strongly con- 
trasting with the exaggerated breath sounds on the normal 
side. Metallic, echoing sound of the voice, obtained by placing 
one ear on the back of the chest-wajl while the assistant taps 
one coin on another on the front of the chest, is constant and 
characteristic. A swashing succussion sound (Hippocratic suc- 
cussion) is produced by shaking the patient while the ausculta- 
tory ear is on his chest; this sound may be heard by the pa- 
tient himself and by others in the room. 

Diagnosis. — This usually is easy, especially in cases of sudden 
and violent onset; careful attention to the physical signs in 
doubtful cases will nearly always solve the difficulty. Emphy- 
sema has the same clear, tympanitic percussion sound, the same 
feeble breath-sounds, and the same difficulty of breathing, but 
in pneumothorax the tympanitic sounds and the feeble breath- 
sounds are more pronounced, there is greater displacement of 
the heart, the "splashing" sound is distinct when there is effu- 
sion, and in many of the cases the beginning of the dyspnoea 
may be traced back to a preceding paroxj^sm of severe pain in 
the chest. Diaphragmatic hernia is differentiated with much 
difficulty ; the chief symptoms indicating it are "the history of 
the case as indicating previous abdominal rather than thoracic 



DISEASES OF THE MEDIASTINUM. 1039 

disease, the absence of cough and expectoration, slight displace- 
ment of the heart, absence of intercostal bulging, and oblitera- 
tion of the area of hepatic or splenic dulness, together with 
signs of the downward dislocation of the liver and spleen" 
(James C. Wilson). 

The prognosis depends largely upon the nature of the primary 
affection. Occurring in a person of good health, it not only 
does not materially shorten life or injure general health, but re- 
covery may take place ; on the other hand, in advanced tuber- 
culosis it forms a threatening complication. The condition 
often is chronic. 

Treatment is that of pleurisy with effusion, including the use 
of a fine aspirator needle for the purpose of allowing some of 
the air to escape, and aspiration in cases of hydro-pneumotho- 
rax. If it causes no inconvenience, interference of any kind is 
inadvisable. Consult remedies applicable to pleuritis, pulmo- 
nary tuberculosis and affections of the lung and pleura gen- 
erally. 



DISEASES OF THE MEDIASTINUM. 



Mediastitiitis may be acute or chronic. The former may be 
idiopathic, but usually is due to traumatism, or accompanies 
infectious fevers and pyaemia, or follows inflammatory affec- 
tions of the organs and structures with which it stands in close 
anatomical relation. It affects males oftener than females, and 
tends to suppuration. 

The symptoms are pain and tenderness under the sternum, 
gradually increasing in severity, with cough, sometimes fol- 
lowed by blood-streaked expectoration; frequently there is con- 
siderable dyspnoea, general malaise, irregular fever, chills and 
sweats. If posteriorly situated, there may be marked 
dysphagia. 

The physical signs are dulness on percussion under the ster- 
num, redness of the skin and feebleness of the heart sounds, 
which appear distant. It is rarely possible to detect pulsation 
or fluctuation. 



1040 DISEASES OF THE RESPIRATORY ORGANS. 

The prognosis must be guarded. The abscess may open ex- 
ternally or into the trachea, bronchi or pleural cavity, or may 
become inspissated and chronic. 

Treatment is directed to the relief of pain and to the support 
of the strength of the patient. As soon as fluctuation can be 
detected, the abscess must be opened. 

Acute lymphadenitis. — Swelling of the mediastinal lymph 
glands takes place in all forms of inflammation of the bronchi 
or lungs (influenza, measles, whooping-cough, broncho-pneu- 
monia, etc.) ; it may also occur in certain infectious diseases 
(typhoid fever, diphtheria, facial erysipelas). 

The symptoms caused are much like those of whooping-cough, 
save that there is not the sharp, shrill inspiratory effort of that 
disease; vomiting may follow the paroxysms of coughing; there 
may be dyspnoea, hoarseness and cyanosis, especially when 
making an effort. If the glandular enlargement is very great, 
the symptoms are those of mediastinal tumor. An abscess ma}' 
form (suppurative lymphadenitis) in simple lymphadenitis ; 
but, as a rule, this tendency belongs to tuberculous cases ; it is 
always dangerous. As a usual thing, the glandular enlarge- 
ment decreases as the primary bronchitis yields, and the symp- 
toms lessen in severity ; in other cases a chronic hypertrophy 
remains, with more or less dyspnoea. It is believed by some 
clinicians that long-continued pressure upon the pulmonary 
artery, from chronic enlargement of the mediastinal lymph 
glands, may induce tuberculous disease of the lungs. 

The treatment consists of rest in bed, nourishing diet, and 
careful attention to the primary disease. The internal adminis- 
tration of Mercury, Iodine and Arsenicum iodatum is likely 
to prove useful. 

Morbid growths found in the mediastinum are cancerous in 
the greater number of cases, but almost any form of morbid 
growth may be met. They occur oftenest in men during the 
fourth decade of life. 

The symptoms caused are chiefly those of intrathoracic pres- 
sure, with such special constitutional S3 r mptoms as belong to 
the character of the growth itself. Derangements of circula- 
tion are important. There is impediment to the return of blood 
through the vena cava superior and its branches, causing con- 
gestion, oedema and cyanosis; the veins themselves, rarely the 



DISEASES OF THE MEDIASTINUM. 1041 

arteries, may become involved in the cancerous growth, and in 
many cases there is marked tendency to thrombosis and ob- 
literation of the veins, resulting in general serous infiltration 
and tumefaction of the face, neck and upper extremities. On 
the other hand, haemoptysis, haemorrhagic effusion into the 
pleura, and infarcts may be similarly produced. Pressure upon 
the arteries diminishes the force of the blood current through 
them, giving rise to a difference in the radial and carotid arte- 
ries of the two sides, as there is also in aneurism of the aorta. 
The heart may be dragged from its natural position by the 
force of the attachments formed and the weight of the tumor, 
or the heart-substance may be invaded, and serous or hsemor- 
rhagic effusion in the pericardium take place. Innervation of 
the heart is seriously affected and its muscular energy greatly 
impaired, disturbing the heart's action and giving rise to palpi- 
tation, f aintness, nausea and vomiting and to abnormal sounds 
and rhythm. Pain is frequent and depends upon circulatory dis- 
turbances and severe dyspncea, or is of a neuralgic character. 
Implication of the recurrent laryngeal nerve gives rise to paraly- 
sis of the vocal cords and aphonia or to violent paroxysms of 
dyspncea. Distressing spells of cough and intense pain in the 
heart may be wholly of nervous origin. In rare cases paralysis 
of the limbs and trunk results from invasion of the spine. Re- 
spiration is usually normal when the patient is at rest, but se- 
vere dyspncea is at once caused by so slight an exertion as 
change of position ; this tendency is likely to increase with the 
growth of the tumor. Yet cases occur where only slight dysp- 
ncea is felt in connection with an extensive new growth ; in 
others, much suffering is caused even though the tumor be 
small. Bennett points out the striking want of correspondence 
between the physical signs and the functional symptoms. "In 
one case there will be persistent difficulty of breathing, amount- 
ing to orthopncea of the most urgent character, in another 
merely a little quickened respiration — lividity and turgescence of 
features in one case, in another an anaemic aspect." Fever is 
rare. 

Physical Signs. — Inspection. Cyanosis of the upper part of 

the body ; establishment of collateral circulation (enlargement 

of the mammary and epigastric veins) ; orthopncea. Bulging 

of the sternum from the outward pressure of the tumor, or ero- 

66 



1042 DISEASES OF THE RESPIRATORY ORGANS. 

sion of the sternum, part of the growth forming a subcutane- 
ous tumor, sometimes pulsating like an aneurism; occasionally 
destruction of the soft tissues and perforation of the chest 
wall. Displacement of the heart often. Palpation: absence of 
fremitus if the tumor presses against the chest wall. Ausculta- 
tion : vocal resonance usually absent. Respiratory murmur 
feeble or wholly wanting ; heart-sounds absent. 

The diagnosis is almost impossible in the early stage, and at 
all times rests upon the "want of correspondence with the ordi- 
nary forms of thoracic disease, the very general signs of the 
presence of pressure and mechanical derangement and the vary- 
ing aspects of these signs." The resemblance to aneurism is 
striking; the most important points to be remembered, as espe- 
cially characteristic of aneurism, are: the "diastolic shock" 
over the sac ; forcible, heaving, expansile pulsations of the tu- 
mor, if external; radiating pains in the back, arms and neck. 
The possibility of a pleural effusion in these cases must be borne 
in mind. 

The prognosis is serious, a fatal termination usually taking 
place in from three to eight months, though exceptionally life 
may be prolonged for several years. Malignant growths de- 
velop with great rapidity and have a comparatively short dur- 
ation. Lymphadenoma and lymphosarcoma run a compara- 
tively slow course, frequently attain an enormous size, and may 
involve all the structures within the thorax. 

Treatment. — If the tumor is favorably situated, surgical 
treatment is practical and may prove equivalent to a cure. 
Other means are purely palliative, and the exhibition of opium 
in some form essentially becomes a necessity. Complications 
must be met according to circumstances and symptoms ; reme- 
dies are exhibited according to the indications. 

Abscess of the Mediastinum is usually the result of an injur3% 
and occurs oftenest in the anterior mediastinum ; if chronic, it 
is almost always of tuberculous origin. 

Of the symptoms, throbbing pain behind the sternum is the 
most conspicuous ; chills and sweats are commonly present, 
with more or less dyspnoea if the swelling is great. Burrowing 
of pus constitutes a dangerous possibility of acute abscess, 
though the pus may become inspissated, as is quite common in 
chronic abscess. 



DISEASES OF THE MEDIASTINUM. 1043 

The diagnosis is indefinite, depending upon the presence of a 
pulsating, fluctuating tumor at the border of the sternum or at 
the sternal notch, with the absence of characteristic symptoms 
of aneurism. 

Emphysema of the Mediastinum is a rare affection occurring 
in exceptional cases of diphtheria, whooping-cough, and from 
trauma. It may be associated with pneumothorax, and is seen 
with relative frequency in cases of tracheotomy. According to 
Champneys, the conditions responsible for its occurrence in 
cases of tracheotomy are : division of the deep fascia, obstruc- 
tion of the air passages, and inspiratory efforts. 

Affections of the Thymus Gland consist of abscess, haemor- 
rhage, and sarcoma and carcinoma. Enlargement of the gland 
is often found post-mortem in case of sudden death in chil- 
dren ; spasms of the glottis (thymic asthma) are frequently as- 
sociated with this condition. It is thought that death may be 
caused by pressure of the hypertrophied gland upon the trachea 
while the head is bent backward. Abscess of the thymus gland 
is an occasional feature of congenital syphilis, though it is seen, 
rarely, in non-syphilitic children. Haemorrhage into the thymus 
gland has been found in purpura and scurvy and other haemor- 
rhagic diseases. Sarcoma and carcinoma of the thymus gland 
are secondary to malignant tumors of the anterior medias- 
tinum. 



PART VIII. 

DISEASES OF THE ORGANS OF 
CIRCULATION. 



PART VIII. 

Diseases of the Organs of Circulation. 

DISEASES OF THE PERICARDIUM. 

PERICARDITIS. 

An inflammation of the pericardium which may be acute or 
chronic, and which is characterized by a fibrinous (plastic) or 
fluid (sero-fibrinous, hemorrhagic or purulent) exudation, with 
a tendency to the formation of fibrinous adhesions {adherent 
pericarditis). 

Etiology. — Pericarditis occurs in any climate and at any pe- 
riod of life, somewhat oftener in males than in females. As a 
primary affection it is rare ; it is oftenest seen in children or as 
the result of traumatism. Secondary pericarditis is of frequent 
occurrence in connection with acute articular rheumatism, from 
30 to 70 per cent, of the latter affection, including tonsillitis and 
chorea of rheumatic subjects, presenting inflammation of the 
pericardium. In other cases the pericardium becomes involved 
through extension of disease from adjacent organs or struct- 
ures ; this takes place frequently in pleuro-pneumonia, especially 
of children and alcoholics, and, less often, in pleuritis, endocar- 
ditis, myocarditis, valvulitis and inflammatory affections of the 
oesophagus, mediastinal glands, adjacent bony structures or, 
rarely, of the abdominal organs. Septic processes (puerperal 
fever, acute necrosis of bone, etc.), tuberculosis, Bright's dis- 
ease, influenza, gout, scurvy, diabetes, low states of the system 
and eruptive diseases of childhood are frequently associated 
with pericarditis ; among these, Bright's disease and scarlatina 
are especially prominent. 

Acute Plastic Pericarditis is almost always secondary. It is 



1048 DISEASES OF THE ORGANS OF CIRCULATION. 

the most frequent and benign form of pericarditis. It may in 
volve a part of the pericardium or may be diffuse and general , 
The pericardium at first is injected and lustreless ; it is soon cov- 
ered with a thin layer of exudation which is easily separated. 
As the exudation increases, friction of the surfaces produces a 
roughened, ridge-like, shaggy appearance (cor villosum), and in 
bad cases the exudate, which may reach one-third to one-half 
inch in thickness, occurs in long, coarse shreds. Evidence of tu- 
berculosis is frequently present, but is easily overlooked. There 
is invariably more or less effusion. The heart muscle is not 
affected, save in severe cases, when it looks pale and turbid. 

The symptoms in the majority of cases are vague, so that the 
disease may not even be suggested during life. Pain may, or 
may not, be present. Sometimes there is tenderness to pressure 
over the prascordia or in the epigastric region, and occasionally 
this is sufficiently severe to resemble an angina, sharp, lancinat- 
ing, and radiating into the left shoulder and arm. Fever, when 
present, is usually moderate, the temperature not exceeding 
102° or 102.5° ; exceptionally, as in some cases of acute articu- 
lar rheumatism, the fever is high, but this depends upon the se- 
verity of the primary disease. 

Physical Signs.— The friction-sounds may be obtained from 
both palpation and percussion. — Palpation. Though by no 
means constant, rough friction fremitus is frequently felt, espe- 
cially when the pericarditis is intense. It is most pronounced 
during the time of the heart's impulse, is rough and grating, 
and seems to be near the surface.— Percussion. Here the fric- 
tion is quite constant. It is usually double (to and fro pericar* 
dial rub), but may be single or triple. It possesses a harsh 
grating quality, and sometimes "creaks," like new leather. 
The heart-sounds often can be heard above the friction sound, 
and may linger after it ; they are obscured when the friction 
sound is very pronounced. The friction sound is close to the 
ear, near the surface, and is usually best heard over the right 
ventricle or at the base of the heart, rarely at the apex ; it is in- 
tensified from pressure with the ear or stethoscope, from taking 
a full inspiration, and from assuming an erect posture; it is 
very variable in position and quality. 

The diagnosis depends upon the presence of the friction- 
sound, its nearness to the ear, and its relation to the heart- 



PERICARDITIS. 1049 

impulse. Pleural friction has similar qualities, but the sound 
is synchronous with the respiratory act and disappears when 
the breath is held. The murmur in aortic incompetency is differ- 
entiated by its constancy, the direction of its transmission (the 
systolic upward into the vessels of the neck, the diastolic down 
the sternum ) , and the history and other symptoms of chronic 
disease of the heart. 

The prognosis in simple pericarditis is favorable, even in scar- 
latina and rheumatism ; it is more serious in cases character- 
ized by a low state of vitality, as in Bright's disease. Adhe- 
sions often take place, but are not necessarily serious. The 
affection may become chronic, especially in tuberculous cases, 
and then extensive thickening and short, firm adhesions may 
result, interfering with the free movements of the heart, a con- 
dition which results in compensatory hypertrophy of the heart, 
followed by dilatation and inadequacy. In other cases exten- 
sive effusion may take place. 

Pericarditis with Effusion. — This form is common in rheu- 
matic affections, in tuberculosis and septicaemia ; it is to all in- 
tents and purposes the second stage of dry pericarditis and is 
treated as such by many writers. The effusion, which varies 
greatly in amount, and may occasionally be excessive, may be 
sero-fibrinous, purulent or haemorrhagic. It is sero-fibrinous 
usually in idiopathic and rheumatic cases ; the pericardium is 
covered with a thick, creamy layer of fibrin, which from fric- 
tion is rolled up in ridges, or appears honey-combed, or in long 
villous extensions. There is more or less thickness of the peri- 
cardial layers, which may assume an almost "leathery" con- 
sistency. Purulent effusion is most frequent in cases dependent 
upon tuberculosis, influenza (Pepper), empyema and suppura- 
tion of glands and bony structures. In many cases the effusion 
is in reality sero-purulent, containing flocculi of fibrin ; in 
others, especially tuberculous or cancerous cases, it is thick and 
creamy. Haemorrhagic effusion occurs oftenest in tuberculous 
or cancerous pericarditis and in debilitated purpuric, scorbutic, 
depraved systems and in the aged. Both pericardial surfaces 
are injected and show haemorrhagic spots. The effusion, in the 
dependent parts, contains thick, curdy masses of lymph. Re- 
sorption of the effusion may be complete, or there may be ag- 
glutination of the adjacent pericardial surfaces, resulting in ad- 



1050 DISEASES OF THE ORGANS OF CIRCULATION. 

hesions, either by loose long bands or uniform and firm. As in 
pleuritis, purulent effusion often leads to thick, cheesy deposits 
upon the serous membrane, with frequently calcareous de- 
posits. The heart muscle is often involved in fatty and granu- 
lar changes which usually do not reach a great depth, but may 
be extensive if the inflammatory action was intense. As 
stated, compensatory hypertrophy of the heart, eventually fol- 
lowed by dilatation, is the result of the extra strain put upon 
the heart by extensive adhesions. Purulent nryocarditis may 
follow purulent pericarditis. 

Symptoms. — The onset is usually insidious, sometimes in no 
sense characteristic, and the presence of the effusion may be the 
first expression of the pericarditis. Pain, sometimes very slight 
and dull, again sharp and lancinating, often provoked by pres- 
sure at the lower sternum, is more frequent in this form than in 
dr}', plastic pericarditis ; it may grow better or worse as the 
pericardial sac is distended by the fluid. Fever usually is mod- 
erate. The pulse at first is normally full, but later becomes 
weak and rapid, and in some cases is eventually lost during 
each inspiration (pulsus paradoxus). Dyspnoea is usually an 
early symptom, and grows worse as the effects of the pressure 
upon the heart grow more pronounced ; it is accompanied with 
restlessness and inability to maintain the recumbent position ; 
the patient looks anxious and distressed, and the countenance 
appears dusk}\ As the amount of fluid increases, the action of 
the heart becomes more seriously embarrassed and the dysp- 
noea, still increased by the pressure of the fluid upon the lung 
and diaphragm, amounts to a sense of impending suffocation. 
Pressure upon the trachea causes distension of the veins of the 
neck, and even fulness of the superficial veins of the thorax, 
d3'sphagia, and dr3% hacking, irritative cough ; aphonia is a not 
uncommon symptom, from pressure upon the left recurrent 
laryngeal nerve. Important nervous symptoms appear, the re- 
sult of the primary rheumatism rather than of the pericardial 
involvement ; in these cases hyperpyrexia is persistent and ac- 
companied by delirium, sometimes resembling delirium tremens, 
or by melancholia with suicidal tendency ; these mental disturb- 
ances are not permanent. In other cases the restlessness be- 
comes excessive and assumes the form of insomnia, delirium and 
coma. Chorea and, rarely, epilepsy have been noticed, the lat- 



PERICARDITIS. 1051 

ter during paracentesis. Dropsy develops with increasing car- 
diac failure, and death from heart failure may occur upon very 
slight exertion. 

Physical Signs. — Inspection, if the effusion is large, may 
show an actual increase of the left side, determined by careful 
measurements ; in children there is quite often decided bulging 
in the pericardial region and between the costal cartilages. The 
pressure from the fluid results in diminished respiratory expan- 
sion on the left side and, if strongly exerted downward, in a 
tumor-like fulness in the epigastric region; the heart is dis- 
placed upward and forward, and a diffuse pulsation may be 
detected in the third or fourth interspaces ; often the cardiac 
impulse is invisible. Fluctuation, upon palpation, is rarely, if 
ever, detected. — Percussion. Increasing area of pericardial dul- 
ness, changing with the position of the patient, somewhat pear- 
shaped, with base down, most marked transversely toward the 
right nipple, extending beyond the reach of the cardiac impulse. 
Absence of resonance in the right fifth intercostal space 
(Rotch). — Auscultation. Disappearance of the friction sound, 
except at the base of the heart ; it returns with the absorption 
of the fluid. Increasing weakness of the heart-sounds ; they be- 
come more and more muffled and finally disappear, first in the 
region of the apex. Diminution of resonance in the left lung, 
and bronchial breathing, from pressure upon the left lung. 

The course of the disease in many cases is rapid, and the ter- 
mination favorable. The effusion may take place within forty- 
eight hours and, even though large, be absorbed quickly. Other 
cases occur where the patient lingers for weeks, both effusion 
and absorption proceeding slowly. Cases with sero-fibrinous 
effusion, and secondary upon rheumatism, usually recover; ad- 
hesions, however, invariably form, and in themselves constitute 
a serious sequel, if extensive. If the effusion is exceptionally 
great, the patient may die from asthma in the second or third 
week ; there is also danger of death from syncope after an exer- 
tion. Septic cases are characterized by the rapid formation of 
pus and fatal issue within a few days. Cases with purulent 
effusion are always dangerous. 

The prognosis is rendered grave by the existence of serious 
heart lesions, extensive pleuritis or pneumonia, and the stub- 
born hyperpyrexia in rheumatic cases ; recovery is rare in the 
presence of tuberculous or malignant disease. 



1052 DISEASES OF THE ORGANS OF CIRCULATION. 

Diagnosis. — Effusion in the pleura is often mistaken for effu- 
sion in the pericardium. "But a pericarditis uncomplicated 
with pleurisy or with pleuro-pneumonia does not change the 
clear sounds at the back of the chest, save in very rare cases of 
enormous accumulation of fluid. Effusion into the pleura gives 
rise to a flat sound anteriorly ; to a still more perceptible dul- 
ness at the inferior portion of the chest posteriorly ; and the 
sounds of the heart remain unaltered, unless its investing mem- 
brane contain fluid also" (Da Costa). — Dilatation of the heart 
in many respects closely resembles pericardial effusion. Osier 
points out the following : in dilatation, the impulse, especially 
in thin-chested people, is usually visible and wavy ; the shock 
of the cardiac sounds is more distinctly palpable in dilatation ; 
the area of dulness in dilatation rarely has a triangular form, 
nor does it, except in cases of mitral stenosis, reach so high 
along the left sternal margin nor so low in the fifth and sixth 
interspaces without visible or palpable impulse. An upper limit 
of dulness shifting with the position speaks strongly for effu- 
sion. In dilatation the heart-sounds are clearer, often sharper, 
valvular, or foetal in character ; whereas in effusion the heart- 
sounds are distant and muffled. Rarely in dilatation is the dis- 
tension sufficient to compress the lung and produce the tympa- 
nitic note in the axillary region. 

Treatment. — It is evident that complete rest, mental as well 
as phj^sical, is absolutely necessar}*-. Whatever excites the ac- 
tion of the heart is to be carefully avoided, and special pains 
must be taken to guard the patient when there is extensive effu- 
sion, since even a slight exertion may bring on syncope with 
fatal results. In plastic pericarditis blistering over the heart has 
still earnest advocates, but it is not as generally recommended 
as ice bags at the prascordia. It is claimed that by this treat- 
ment, maintained at first for one or two hours at a time, then 
continuously, the action of the heart is retarded and the danger 
of effusion much lessened. In full-blooded persons bleeding by 
leeches may be advisable. After effusion has taken place, meas- 
ures to promote its resorption are indicated. Clinical evidence 
shows that here blistering is of positive service. A purge of 
Epsom or Rochelle salts, every other morning, may be ordered 
if the patient is sufficiently robust. Pepper recommends the 
iodide of potash, ten grains three times each day, particularly 



PERICARDITIS. 1053 

when the case has become chronic. Hyperpyrexia, if persistent, 
demands the cold pack or ice. Surgical measures are indicated 
as soon as the heart shows inability to carry on its function 
and there is great dyspnoea, small pulse, venous congestion, etc. 
The aspirator may be used if the history of the case warrants 
the presumption that the effusion is sero-fibrinous or when ex- 
ploratory puncture demonstrates that such is the case. The 
puncture should be made in the fourth or fifth interspace, in the 
former at, or within an inch of, the left sternal margin ; in the 
latter from 1^ to 2% inches from the sternum. Occasional in- 
jury by puncture of the heart itself has proved free from serious 
results. Free incision into the pericardium is practiced when 
the effusion is purulent. The more radical operation so far has 
been disappointing in its results, a fact attributed by its advo- 
cates to unwarrantable delay in performing incision and to the 
difficulty of maintaining good drainage. The diet throughout 
must be dry, light, and nutritious. 

Therapeutics. — In the first stage Aconite is exceedingly use- 
ful, especially in rheumatic cases. Its characteristic indications 
must be present. — Belladonna, like Aconite, is most useful be- 
fore the inflammatory action has become fully localized. It 
must be consulted in cases of children having scarlet fever and 
in rheumatism, with much redness, tenderness and swelling of 
the joints, and when the symptoms of congestion are well 
marked. It is of great service in cases with pronounced cere- 
bral disturbances, either violent delirium bordering upon mania 
or, later, with tendency to stupor, pallor of the face and threat- 
ening dissolution. — Bryonia is almost as useful here as in pleu- 
risy. The pains are sharp, lancinating, "pleuritic ;" there is op- 
pression over the region of the heart ; characteristic rheumatic 
and gastric symptoms (dryness of the mouth; tongue coated 
white or brownish ; epigastric soreness, often with sensation of 
hard lump in the stomach); scanty urine of acid reaction ; sweat- 
ing.— Veratrum viride is very valuable when, early, there is vio- 
lent and tumultuous action of the heart, so it fairly lifts the chest. 
This condition is oftener seen in full-blooded, powerful men, and 
is associated here with great congestion and high tension, well 
manifested in the full, hard, bounding pulse of such cases. It 
should not be continued too long or given in too large doses. — 
Spigelia is an excellent remedy when there is sharp, stitching 



1054 DISEASES OF THE ORGANS OF CIRCULATION. 

pain in the heart, worse from every movement ; palpitation ; 
ch T spnoea, especially when lying on the back ; dry cough ; rheu- 
matic history ; pleuritic involvement. — Cimicifuga is useful in 
rheumatic cases, sudden and severe in onset. "The fever is not 
high, but the pain is intense. There is excessive impulse of the 
heart over a large space, with increase of dulness on percussion. 
The pain in the heart is diffused all over the left side and ex- 
tends down the left arm. The headache is peculiar, a sensation 
of bursting as if the top would fly off, with violent aching in 
the e} T e balls. The heart's action is violent and irregular 
(choreic). Great depression of spirits, gloonry and taciturn. 
The pains are described as aching, stitching, benumbing or com- 
ing on in sudden shocks" (E. M. Hale). — Kalmia is suggested 
by its close relation to rheumatic affections, shifting in charac- 
ter, going to the heart and involving the arms and shoulders, 
with stiffness and numbness, paralytic weakness and trembling. 
There are paroxysms of intense anguish about the heart, the 
beating of which is rapid, tumultuous, visible. It resembles 
Aconite and Cimicifuga. Asclepias tuberosa, Ranunculus 
and Squilla should be consulted. 

Effusion having taken place, and the remedies already enum- 
erated proving insufficient, Apis, Colchicum, Kali hydriodi- 
cum, Cactus and possibly Sulphur should be carefully studied, 
particularly with reference to their general, constitutional indi- 
cations. Thus, Apis is likely to prove useful when there is a 
tendency to general dropsy, with great scantiness and almost 
suppression of the urine ; great "soreness" over the heart. — Col- 
chicum has very positive rheumatic symptoms, with tearing, 
jerking pains and tendency to involve the heart. There is little 
fever, hot and moist skin, and weak, intermitting, quick 
pulse. The pain about the heart is severe, with much dyspnoea, 
and in character resembles the squeezing, constrictive, band-like 
pain of Cactus. Occasionally the characteristic gastric symp- 
toms are present (craving for various things ; if they are 
brought to him, especially when he smells them, they "turn his 
stomach" and he cannot eat them). — Kali iodatum, in com- 
paratively light doses, five to ten grains three times daily, is 
highly recommended by the physiological school, and many 
cures with it of effusion within the thorax have been reported 
by homoeopaths. It is known to be an excellent remedy in suba- 



CHRONIC ADHESIVE PERICARDITIS. 1055 

cute articular rheumatism. It has constant dyspnoea, and cough 
with expectoration like soap-suds. Hale claims to have had 
good results from it in alternation with Digitalis and, espe- 
cially, Convallaria, the latter assisting its action as a heart- 
tonic. "Sulphur follows Kali iodatum, and rivals it in peri- 
cardial exudations." — Cactus is indicated chiefly by its sense of 
band-like constriction about the heart, giving rise to great 
dyspnoea, sense of suffocation, inability to lie down, and cold 
sweat. — Sulphur has cured "cardiac dropsy," and may prove 
useful here in chronic cases presenting the characteristic consti- 
tutional peculiarities of the remedy. 

It is evident that the entire list of so-called heart-tonics must 
be consulted when this organ gives proof of exhaustion, as oc- 
curs often in severe cases. (See Chapter on Valvular Disease.) 
It must, however, be remembered that frequently prompt relief 
of distressing and threatening conditions can only be brought 
about by the operative measures already indicated. 

CHRONIC ADHESIVE PERICARDITIS. 

Chronic adhesive pericarditis or adherent pericardium con- 
sists of more or less extensive agglutination and adhesion be- 
tween the pericardial layers, resulting from connective-tissue 
formation which follows acute inflammation of the membrane. 
The lighter forms of adherent pericardium follow the simple 
plastic cases of pericarditis, chiefly of rheumatic origin. In 
some of these the adhesions consist of only a few bands, which 
do not to any extent interfere with the freedom of the heart's 
action. In others the adhesion is firmer and more extensive, 
and the thickening much greater. Chronic tuberculous cases 
are usually characterized by extensive adhesions and great 
thickening, with serious interference with the action of the 
heart, causing compensatory hypertrophy of that organ, fol- 
lowed by degeneration and dilatation. In pericarditis with co- 
pious effusion of sero-purulent or purulent character, inspissa- 
tion of the remnant of the effusion and calcification, most 
marked about the base of the heart, are frequently observed, 
and in exceptional cases the entire heart may be held in a calca- 
reous investing membrane. 

The symptoms are indefinite, and the condition may entirely 



1056 DISEASES OF THE ORGANS OF CIRCULATION. 

escape observation during life unless there is a considerable de- 
gree of heart failure, in which case irregularity of the pulse, 
cyanosis and other characteristic symptoms are present. In 
some cases there is weakness of the pulse, worse during inspira- 
tion (pulsus paradoxus). 

The physical signs are somewhat more distinctive, but not 
clear-cut. Of special value is the systolic retraction of the chest, 
usually plainest at the apex ; it is strongly emphasized when 
there are also extra-pericardial adhesions with the heart and 
with the chest wall ; the more extensive the systolic retraction, 
the more valuable the sign, which is most pronounced during 
inspiration. Friedreich's sign, "diastolic collapse," consists of 
a sudden collapse of the jugular veins at each diastole, to be 
filled again during the next systole; it is comparatively rare and 
uncertain. The area of cardiac dulness is increased, especially 
upward, even as high as the second or, rarely, first interspace, 
but it is not affected by a change in the patient's position, nor 
is it pear-shaped. 

The duration of the disease is uncertain. As stated, light 
cases rarely attract attention ; in severe cases it is the eventual 
occurrence of dilatation of the heart which demands relief. 

The treatment will be considered later. 

HVDROPERICARDIU9I. 

"Dropsy of the heart" is usually seen in connection with the 
general dropsy of renal (Bright's) and cardiac (valvular) dis- 
ease. Rarely it follows scarlet fever or profoundly anaemic or 
cachectic states. The fluid is of light-yellow color, sometimes 
turbid, and frequently tinged with blood or biliary matter; oc- 
casionally it is chylous. 

The symptoms and physical signs are those of effusion and 
pressure. If the effusion takes place gradually, there may be no 
appreciable disturbance. Friction -sound is never present. 

The diagnosis rests upon the history of the case, the exist- 
ence, usually 1 , of general dropsy, and the absence of friction 
sound. 

The prognosis is necessarily grave. 

Treatment must be directed to the cause and, in addition to 
such remedies as are indicated symptomatically, may call for 
surgical measures (aspiration). 



H^EMOPERICARDIUM. 1057 



HJEMOPERICARDIUM. 



Haemorrhage into the heart's sac occurs from rupture of the 
first part of the aorta, pf the coronary arteries, of the heart 
wall (in myocarditis), or as the result of injuries to the walls 
of blood vessels, as from penetrating wounds. 

The symptoms are those of haemorrhage and heart failure. 
They are especially severe and rapidly fatal in the bursting of 
an aneurism. In spontaneous rupture of the heart there are 
signs of effusion, with heart failure ; life may be maintained for 
several days. The physical signs are those of a moderate effu- 
sion. 

The prognosis is necessarily hopeless, save in cases where the 
haemorrhage is insignificant and may be absorbed. 

Treatment consists of absolute rest, the exhibition of cardiac 
stimulants and, possibly, paracentesis. 

PNEUMOPERICARDIUM. 

The presence of air in the pericardial sac is a rare event, and 
almost invariably results from a penetrating wound of the 
chest or from perforation of the lung, stomach, or oesophagus 
(ulcers or cancer). Pericarditis is always present, followed by 
rapid effusion, more frequently purulent. ''When the effusion is 
copious, the fluid and gas together give a movable area of per- 
cussion dulness with marked tympany in the region of the gas. 
On auscultation, remarkable splashing, churning, metallic phe- 
nomena are heard with friction and possibly feeble, distant 
heart sounds" (Osier). The termination is rapidly fatal. 



DISEASES OP THE ENDOCARDIUM. 

ENDOCARDITIS. 

Inflammation of the endocardium is usually limited to the 
valves. It is rarely a primary disease, but occurs in the course 
of, and as a complication in, infectious diseases. Clinically, 
two forms are recognized : acute or simple and chronic or ma- 
lignant endocarditis. 
67 



1058 DISEASES OF THE ORGANS OF CIRCULATION. 

ACUTE OR SIMPLE ENDOCARDITIS. 

./Etiology. — Simple endocarditis is wholly a secondary affec- 
tion ; even in cases which appear primary it is safe to assume 
that it is based upon a latent rheumatic tendency. It is most 
frequently associated with acute articular rheumatism (60 to 
80 percent.), and Pepper states that "rheumatic endocarditis 
seems rather a special localization of the rheumatic disease than 
a secondary affection to which a prolonged and debilitating 
disease has rendered the system liable." It is also of frequent 
occurrence in tonsillitis, an affection closely allied to rheuma- 
tism. It may be a complication, usually late, of scarlatina, 
much more rarely in measles, chicken-pox, typhoid fever, pneu- 
monia, phthisis, and in affections characterized by progressive 
emaciation and exhaustion, as cancer, diabetes, Bright's dis- 
ease ; it is also seen in gout, gonorrhoea, pyaemia and septic con- 
ditions. In chorea the endocardium is quite often involved, 
Osier having found simple warty vegetations on the valves in 
sixty-two of sevent}'-three cases of fatal termination collected 
by him. The same marked tendency to endocardial involve- 
ment exists in chronic valvular disease. Generally speaking, 
simple endocarditis occurs oftener in childhood than in adult 
life, and among adults oftener in men than in women. Preg- 
nancy and the puerperal state are said to be predisposing 
causes. 

Morbid Anatomy. — The affected endothelium is covered with 
minute "warty" or verrucose growths, rarely exceeding 4mm., 
often attached by a delicate pellicle. There is small-celled infil- 
tration of the subendothelial connective tissue and superficial 
coagulative necrosis, with thin layer of fibrinous exudation. 
"A vegetation is a small area of granulation tissue capped with 
fibrin." The left side of the heart is much more commonly 
affected; in fcetal life the reverse is the case. There is a marked 
preference for the mitral valve over the aortic. In either case the 
vegetations occur in a row of small bead-like elevations at 2 to 
3 mm. from the free margin of the valve, i. e., at the point of 
maximum contact on closure. 

Resolution may take place by absorption, but it is rarely 
complete ; or there may be increased proliferation of the con- 
nective tissue elements of the valve, often involving the chordae 



ACUTE OR SIMPLE ENDOCARDITIS. 1059 

tendineae and giving rise to danger of adhesion of leaflets or of 
the valve to the wall of the heart or the aorta. It is also pos- 
sible that a vegetation may be detached and carried into the 
circulation, constituting an embolus, leading to infarction* 
usually of the kidneys, spleen, brain or lungs, or exceptionally 
to the formation of abscesses in these organs if micro-organ- 
isms were present. 

Symptoms. — Scarcely a disease known is so easily over- 
looked, for there is a remarkable absence of characteristic 
symptoms or physical signs. Cases will go on to a fatal termi- 
nation without a suspicion of the fact that endocarditis is re- 
sponsible for the mischief, until revealed by examination after 
death. In some cases of acute articular rheumatism endocar- 
ditis may be suspected when there is an increase of the rapidity 
of the heart's action, with some irregularity, increase of fever, 
some dyspnoea and, exceptionally, pain at the heart, without 
increase of the articular disease ; but more frequently nothing 
occurs to arouse suspicion. Physical signs are equally indis- 
tinct until marked hypertrophy and dilatation have taken 
place, when both symptoms and signs are characteristic of that 
condition. 

Complications and Sequels. — Of the complications likely to 
arise, myocarditis is the most common. Pericarditis may exist 
or take place from extension. Pleurisy or pneumonia may re- 
sult from impeded pulmonary circulation. Rupture of the 
chordae tendineae of a papillary muscle is not infrequent. The 
possible occurrence of embolism has been mentioned; it oftenest 
involves the kidneys, next in the order of frequency the spleen, 
very rarely the brain and skin ; if the right heart is the seat of 
the endocarditis, the lungs are involved first. Embolism, how- 
ever, is a much more common sequel in the malignant form of 
endocarditis. 

The diagnosis is necessarily uncertain. 

The prognosis in uncomplicated cases, especially in children, 
is favorable ; complications add much to the seriousness of the 
case; the recurring form, which is common in rheumatic cases, 
has a strong tendency to result in valvular disease of the heart, 
a fact which must always be borne in mind. 

Treatment. — The knowledge that endocarditis is liable to set 
in during the course of certain affections, notably acute articu- 



1060 DISEASES OF THE ORGANS OF CIRCULATION. 

lar rheumatism, suggests efforts to forestall such an occurrence. 
No preventive measure is so important as the enforcement of 
absolute bodily and mental rest and avoidance of any influence 
which may excite the action of the heart. It is equally neces- 
sary to maintain an even temperature (72° to 75° F.) and to 
guard the patient against draughts. 

MALIGNANT ENDOCARDITIS. 

The term "malignant" endocarditis embraces the so-called 
"infectious," "ulcerative," "diphtheritic" and "mycotic" forms 
of endocarditis. 

^Etiology. — Exceptionally malignant endocarditis is pri- 
mary. Of the diseases with which it is associated as a second- 
ar} r affection, pneumonia heads the list. Rheumatism is much 
less often complicated with the malignant than with the simple 
form of endocarditis, statistics showing that the former is 
found in only 8 or 9 per cent, of cases. It is seen in erysipelas, 
septicaemia, puerperal fever and gonorrhoea, and in septic pro- 
cesses generally. Puerperal endocarditis is more frequent after 
abortion than after labor at full term, and (as in rheumatism) 
is more likely to occur during the first week of the fever. It is 
rare in chorea, typhoid fever, tuberculosis, diphtheria, and oc- 
curs only exceptionally in small-pox and scarlet fever. While 
no age seems exempt, by far the greater number of cases occur 
during the fourth decade of life. The existence of old valvular 
lesions is a strongly predisposing factor. Alcoholism, expo- 
sure, unhealthful living and bad habits are predisposing causes, 
largely because they vitiate the system and lessen its powers of 
resistance to disease. 

Morbid Anatomy.— The essential lesions are vegetative, ul- 
cerative, or suppurative ; one or the other may be well pro- 
nounced, and all may be present in the same case; all are char- 
acterized by necrosis and loss of tissue. The vegetations resem- 
ble those of the simple form, but are larger and more luxuriant; 
in case of ulceration they usually present a greenish color and 
may be encrusted with lime salts ; small abscesses often occur 
at their base. Ulceration may be superficial, confined to the en- 
docardium, or deep ; if the latter, it leads to perforation of the 
valve segment, or septum, or of the heart itself, and by exten- 



MALIGNANT ENDOCARDITIS. 1061 

sion may give rise to valvular and even partial cardiac aneur- 
ism or, rarely, to purulent myocarditis or pericarditis. Suppur- 
ation first affects the deeper tissues of the valve and is frequent 
at the base of the vegetation. The mitral and aortic valves are 
by far the favorite seat of the disease ; the heart-wall, in a series 
of 209 cases collected by Osier, was affected in 33 cases. Of 
these, involvement of the upper part of the septum of the left 
ventricle and of the posterior -wall of the left auricle were the 
more frequent. Ulcerative processes, as indicated, may lead to 
erosion and perforation, with more or less complete destruc- 
tion of the valve, chordae tendineae, septum, heart wall, and the 
formation, less frequently, of aneurism. The distant changes 
are characteristic of the primary disease, of distinctly septic 
processes, and of embolism. The infarcts are red or white, sup- 
purative, and vary exceedingly in numbers. They are found in 
the spleen, kidneys, brain and lungs, the latter if the tricuspid 
or pulmonary valve is involved. In pyaemic cases multiple 
miliary abscesses are frequent. Minute haemorrhages into the 
skin, serous surfaces and retina often result from the embolism. 
Acute suppurative meningitis occurs in about ten per cent, of 
all the cases studied ; acute suppurative parotitis has also been 
observed. 

Symptoms. — The clinical history is exceedingly varied and 
striking in the absence of clear-cut, characteristic symptoms ; 
the absence of characteristic signs (physical) adds to the diffi- 
culty of a satisfactory description of the disease and to the un- 
certainty of the diagnosis. It is possible that the presence of 
symptoms which suggest pyaemia — as irregular fever, copious 
and excessive sweating, delirium, gradual failure of strength- 
is most conspicuous, and whenever these assert themselves in 
the course of an acute disease with which endocarditis may be 
associated, suspicion of cardiac trouble is warranted. 

The onset of endocarditis is frequently marked by a chill, fol- 
lowed by irregular fever, remittent or intermittent, with an 
evening temperature rarely exceeding 104° F. ; sometimes, 
however, the fever is continuous and the temperature persist- 
ently high. Repeated rigors, drenching sweats, and great ex- 
haustion follow; the sweating in severity often exceeds that of 
phthisis and ague. The spleen frequently is enlarged and ten- 
der, the urine albuminous, and gastro-intestinal irritation, espe- 



1062 DISEASES OF THE ORGANS OF CIRCULATION. 

cially nausea and vomiting, may be pronounced. Slight com- 
plaint, and frequently none whatever, is made of the heart ; 
there is rarely pain, but the patient may have some palpita- 
tion, slight dyspnoea, and a sense of oppression or constric- 
tion. Headache, restlessness, and slight mutterings, with a 
tendency to stupor, are common ; in severe cases the nervous 
symptoms are sufficiently marked to constitute a distinct type 
of the disease. Jaundice is not uncommon ; erythematous and 
petechial rashes are often seen, and may add to the uncertainty 
which surrounds the case. J 

The clinician easily recognizes distinct types of malignant en- 
docarditis. Of these the typhoid form is the most common. 
Here the early prostration, the pronounced character of the 
nervous sj^mptoms (delirium, somnolence, coma), the diarrhoea, 
sweating and copious petechial eruption, with, often, an ab- 
sence of distinct heart symptoms, is calculated to mislead the 
most experienced practitioner. The septic (or pysemic) form 
occurs oftenest in connection with puerperal processes, necrosis 
of bone or external suppuration. It has the characteristics of 
pyaemia ; here, also, the heart-symptoms may be completely 
masked, and the true nature of the difficulty may easily be 
overlooked unless the occurrence of embolism solves the diffi- 
culty. These cases may closely resemble severe malarial fever. 
Again, the cerebral symptoms may be so pronounced as to 
suggest a meningitis. In chronic valvular disease, also, there 
appear at times, without cause and with great suddenness, high 
fever and symptoms of endocarditis which may assume a septic 
or typhoid form and frequently run a rapidly fatal course. 

Embolism gives rise to symptoms which usually are recog- 
nized without much difficulty. If the infarction occurs in the 
spleen, there is likely to be swelling of that organ, with pain 
and localized peritonitis; if in the kidneys, and of sufficient size 
to cause trouble, there is lumbar pain and highly albuminous 
and bloody urine ; if in the brain, the symptoms vary with the 
seat of the obstruction and the lesions resulting from it, but 
delirium, coma and paralysis are quite sure to supervene. In 
addition, dimness of vision, retinal haemorrhage, jaundice, ery- 
thema or petechia?, suppuration, and even gangrene, may de- 
velop. 

The course of malignant endocarditis depends largely upon 



MALIGNANT ENDOCARDITIS. 1063 

the primary disease with which it is associated ; it rarely ex- 
ceeds five or six weeks, save in the form which occurs in connec- 
tion with chronic valvular disease; here it may continue for 
months. 

The prognosis in the genuine malignant form is unfavorable; 
cases are occasionally reported cured, but it is probable that 
these were of the simple form. 

Diagnosis. — The difficulty of the diagnosis has been discussed. 

From simple endocarditis the malignant form is differentiated 
by the greater severity of the constitutional symptoms, the oc- 
currence of rigors, height of fever, the copious sweating, the 
marked involvement of the nervous system, and the septic or 
typhoid coloring of the case. From typhoid fever it is distin- 
guished by the usually more abrupt onset, the irregularity of 
the fever, the greater frequency of albuminuria with casts, and, 
if these are present, the oppression about the heart, palpitation, 
and cardiac pain. Compared with rheumatic fever, it has 
splenic enlargement, petechise, albuminous urine with casts. 
Differentiation from pyaemia is unnecessary, since malignant 
endocarditis is practically a pyasmic process. In all cases the 
appearance of symptoms denoting embolism clears up the di- 
agnosis. 

Treatment. — The treatment is largely that of pyaemia. Diet 
must be nourishing and easily assimilated, and rectal alimenta- 
tion may become necessary through irritability of the stomach 
and vomiting. If in the early stage the action of the heart is 
excited, the external use of cold (bladder filled with cracked ice) 
over the heart is indicated ; later, cardiac tonics are called for. 
Alcoholic stimulants may be demanded. 

Therapeutics of Endocarditis. — Aconite. Its usefulness in 
the early stage is admitted by all schools ; its characteristic in- 
dications need not be repeated. Hale also suggests it when 
there is failure of the heart muscle, with small, thready pulse 
and fluttering heart; cold, clammy skin; patient anxious; intel- 
ligence clear. — Belladonna. General and great congestion. 
Throbbing and violent palpitation of the heart. — Bryonia. 
Rheumatic history and tendency. Stitching pain at the heart. 
Weak, irregular pulse, with violent palpitation from making 
an exertion. — Cactus. Violent palpitation, with determination 
of blood to the head ; intense headache ; nose-bleed ; pricking at 



1064 DISEASES OF THE ORGANS OF CIRCULATION. 

the heart ; sensation as though the heart were compressed in a 
vise or band of iron ; cold sweat, etc. — Cimicifuga. Rheumatic 
cases. Pains extending over the chest and down the left arm, 
with numbness in the arm. Heart's action irregular, tumultu- 
ous, "cranky," jerking, choreic. Dyspnoea; lividity of face ; 
coldness and cold sweating of the hands. Intense frontal head- 
ache, with severe soreness and deep aching of the eyes, with 
great mental depression.— Spigelia. More frequently indicated 
in pericarditis, it is of service in endocardial inflammation when 
there is violent and irregular action of the heart, with severe 
neuralgic pains of a stitching character, dry cough and dysp- 
noea at every change in position. — Veratrum viride. Resem- 
bles Aconite, but has a heavier, firmer, farther-reaching pulse. 
The heart-beat is powerful and the arterial tension high. There 
may be delirium of a wild character; sometimes muttering. As 
with Aconite, Hale thinks Veratrum useful also when the en- 
tire picture has changed and heart failure is indicated. "The 
pulse sinks to 25 or 30 per minute, but remains full and large, but 
very soft; so soft, indeed, as to afford no resistance to the fin- 
ger ; the beats of the heart are the same, or in some instances 
double, two pulsations being required for the half-paralyzed 
ventricle to send the sluggish current to the wrist." 

Endocarditis of a malignant character additionally suggests 
such deeply acting remedies as Arsenic, Crotalus, Lachesis 
and Phosphorus. — Arsenic is indicated by its great depres- 
sion, anguish, restlessness, thirst, profound cachexia, feeble and 
irregular pulse, excessive dyspnoea and general tendency to ma- 
lignancy. — Crotalus and Lachesis cover extreme prostration, 
with characteristic septic conditions, and are particularly ap- 
plicable to cases in which ulcerative processes involve the tissues, 
with septic, pyasmic and hemorrhagic conditions developing. — 
Phosphorus deserves careful study in connection with inflam- 
matory action tending to extensive degeneration and a vitiated 
state. I am not aware of conclusive clinical proof of its effi- 
ciency in malignant endocarditis, but to those familiar with the 
pathogenesy of the drug its applicability, theoretically at least, 
must be evident. 

In case of heart failure Digitalis and other cardiac stimu- 
lants will be demanded ; for hints concerning these, consult the 
treatment of valvular disease ; consult also the therapeutic 
hints given under pericarditis. 



CHRONIC ENDOCARDITIS. 1065 

CHRONIC ENDOCARDITIS (Chronic Valvular 
Disease). 

Chronic, sclerotic or interstitial endocarditis is sometimes a 
primary disease, but usually it is secondary to acute endocar- 
ditis, especially of the simple form, or to rheumatism, chorea, or 
certain infectious diseases. The close relation of endocarditis 
to rheumatism has already been pointed out, and careful ob- 
servers are strongly inclined to believe that even in cases the 
history of which shows no attack of rheumatism, the rheuma- 
tic tendency or element is none the less active as an setiolog- 
ical factor. Other important causes are: violent and prolonged 
muscular exertion ; alcoholism ; gout ; syphilis.— Age. The fre- 
quency with which rheumatic fever attacks the young explains 
the common occurrence of chronic endocarditis in early adult 
life; the mitral valve is here oftenest affected. During foetal 
life the right heart is almost always the seat of the lesion ; in 
old age aortic disease is more common, as it also is in cases 
which result from excessive muscular exertion. — The influence 
of sex is less positive. Women more frequently suffer from rheu- 
matism and chorea, and men oftener from syphilis and gout ; 
in the main, valvular disease is somewhat more common in 
women than in men. F. J. Smith states that mitral stenosis is 
much oftener found in women, and aortic disease about three 
times as often in men as in women. Chronic endocarditis inva- 
riably leads to deformity of the affected valve ; it practically 
constitutes chronic valvular disease, and will be treated as such 
here. 

Morbid Anatomy. — The structural changes begin with a 
slight thickening at the edge of the valve, along the line of 
contact, with, at times, some slight nodules, the remnants of 
the wart-like vegetations seen in the acute form of the disease ; 
the endocardium appears dull, lustreless, opaque, and slowly 
grows in thickness and inelasticity ; this process eventually ex- 
tends throughout the entire valve. The "thickening" is the re- 
sult of connective tissue formation, depending upon prolifera- 
tion of the endothelium and round-cell infiltration of subendo- 
thelial connective tissue. Sclerotic changes take place early ; 
minute areas of fatty degeneration appear here and there; 
later, there is contraction of the fibrous tissue, giving rise to 



1066 DISEASES OF THE ORGANS OF CIRCULATION. 

such a degree of deformity of the valve, i. e., thickening of the 
substance of the segment, with curling at the edges, that it no 
longer "fits" and cannot properly close. In many cases this 
"thickening" involves the chordae tendineae, which are short- 
ened in proportion; agglutination of the neighboring leaflets or 
of a leaflet to the ventricular wall may occur ; or, by extension, 
the integrity of adjacent structures may be seriously affected. 
Contraction of the edges of the valves at their angle causes 
narrowing of the orifice, with associate changes somewhat dif- 
fering in character and effect in the different valves. Necrosis 
leads to ulceration, and often to the deposition of lime salts at 
the free edge, or at the points of attachment, or throughout 
the valve; the valve, in such cases, may have a "mulberrj'-like 
or jagged surface" and its insertion may be represented by a 
calcareous ring. The changes in the heart itself are dilatation 
of the heart cavities and hypertrophy of the heart muscle, the 
seat of these changes depending upon the valve which is 
affected ; with it are noted enlargement of the papillae and tra- 
becular, with thickening and a dark-red, later grayish-red, color 
of the myocardium, thickening of the endocardium, and fibrous 
changes in the wall of the dilated auricle. In congenital cases 
the right side of the heart, especially the tricuspid valve, is 
affected ; in acquired cases the left side more frequently suffers. 
The mitral valve is most frequently diseased ; the aortic valve 
less often, the tricuspid valve occasionally, and the pulmonary 
valve rarely. The disease may be limited to one valve or it may 
simultaneously attack two valves, oftener the mitral valve and 
the aortic, or the mitral and tricuspid; simultaneous disease of 
the mitral, aortic and tricuspid valves is rare ; simultaneous 
disease of all the valves has occurred in very exceptional cases 
only* 

MITRAL INSUFFICIENCY. 

Mitral insufficiency is the commonest form of valvular dis- 
ease, occurring alone in about 40 per cent, of all cases, and in 
many more associated with other forms of valvular disease. 
It is usually secondary to rheumatic endocarditis, hence be- 
longs chiefly to early adult life. It is due to contraction and 
shortening of the segments, generally with narrowing of the 
orifice, or to changes in the muscular wall of the ventricle, 



MITRAL INSUFFICIENCY. 1067 

which either produce sufficient dilatation to prevent perfect 
closure of the orifice by the valve or cause imperfect apposition 
of the segments during the systole (muscular incompetency). 

Morbid Anatomy. — The imperfect closure of the valve causes 
regurgitation of a certain amount of blood from the left ven- 
tricle into the left auricle, leading to dilatation of the left auri- 
cle and hypertrophy of its "wall ; this, however, is never great. 
The left auricle containing the blood received from the lung and 
that regularly thrust back into it from the left ventricle, the 
latter, with each left auricular systole, has forced into it an ab- 
normally large volume of blood ; hence, dilatation of the left 
ventricle. Hypertrophy of the ventricular wall becomes a 
physiological necessity, to enable the left ventricle to bear the 
abnormal pressure. The backward pressure of the blood nec- 
essarily prevents complete emptying of the pulmonary veins, 
which become turgescent and dilated ; pulmonary tension in- 
creases with the growing inability of the right ventricle to 
empty itself; the overburdened ventricle finally becomes ex- 
hausted and its walls yield, resulting in dilatation, often with 
remaining hypertrophy. The right auricle eventually under- 
goes the same change. In the lungs, the dilatation of both ar- 
teries and veins ultimately gives rise to "brown induration," 
at times atheroma. The ventricular hypertrophy may so fully 
compensate for the mischief done by the valvular incompetency 
that for an indefinite period, even many years, no disturbances 
are experienced. As soon, however, as the left ventricle becomes 
unable to do the heavy amount of work placed upon it, the 
lesser circulation becomes engorged and the action of the right 
heart much embarrassed. Finally dilatation of the right auri- 
cle results, the tricuspid valves cease to work perfectly and 
grow insufficient, and there rapidly follow engorgement of the 
systemic veins, cyanotic induration of the viscera and, fre- 
quently, dropsy. 

While perfect compensation may be, and frequently is, main- 
tained for many years, there is constant danger that it may at 
any time be broken by an unusual strain suddenly placed upon 
the heart, a fact the clinical importance of which is easily seen. 
When incompetency results from changes in the muscular 
structures, as impaired nutrition of the mitral and papillary 
muscles, such as occur in alcoholics, in persons suffering from 



1068 DISEASES OF THE ORGANS OF CIRCULATION. 

chronic Bright's disease, and in cases where there is habitual 
strain put upon the heart, the changes are practically identical 
with those produced by lesion of the valve itself, but compen- 
sation is much less perfect. 

Symptoms. — There are no symptoms to betray the develop- 
ment of valvular lesion or its existence while compensation is 
maintained. Extra strain put upon the heart by some special 
exertion may, however, cause slight embarrassment of breath- 
ing when going up-stairs or walking rapidly. Certain symp- 
toms mark the presence of pronounced incompetency ; these are: 
a bluish appearance of the face, lips and ears from congestion 
of the veinules which ma}^ often be seen very plainly on the 
cheeks; shortness of breath ; palpitation. These are not neces- 
sarily very pronounced, and they may be wholly absent ; their 
presence, however, is significant. Many observers add the so- 
called "clubbed -fingers." There is in such cases a tendency to 
bronchitis and haemoptysis which depends upon the existing 
pulmonary congestion. Compensation being broken, the 
heart's action at once becomes markedly irregular, rapid, weak 
and "fluttering ; " often, just at the point of going to sleep, the 
patient is suddenly startled by a sensation as though the heart 
had stopped, or would stop, beating. There is much dyspnoea 
and, frequently, cough, which gradually grows worse, and is 
accompanied with watery or bloody expectoration. The effects 
of venous engorgement and stasis are marked. Dropsical 
symptoms develop, first in the feet, then extending upward and 
involving the serous sacs. There is enlargement of the liver and 
congestion throughout the portal system, with gastric and in- 
testinal catarrh, some jaundice, scanty and albuminous urine, 
with casts and sometimes blood corpuscles. Proper treatment 
of the case may be followed by marked improvement, and the 
patient may remain comfortable for a considerable period of 
time, then again to develop the same train of symptoms. This 
may be repeated several times, death finally taking place from 
general dropsy or gradually supervening heart failure (asys- 
tole). 

Physical Signs. — Inspection. Precordial bulging and diffuse- 
ness of the cardiac impulse, especially marked in children and 
young persons. Apex beat displaced toward the left and down- 
ward (sixth interspace). When there is great dilatation of the 



MITRAL INSUFFICIENCY. 1069 

left ventricle, epigastric pulsation is often observed. — Palpa- 
tion. Apex beat displaced, abnormally strong. Force of im- 
pulse feeble and wavy when there is insufficient compensation ; 
strong and heavy when compensation is good. Pulse may be 
full and regular, but becomes disturbed and irregular from ex- 
ertion and -when compensation is poor. — Percussion. Increase 
of dulness, especially laterally, greater toward the left ; increase 
of dulness in a lateral direction more marked than in any other 
valvular disease. — Auscultation. Systolic murmur at the apex, 
usually harsh and hard, and sometimes audible at some dis- 
tance (six inches, or more) from the chest wall, partly or wholly 
obliterating the first sound. Sometimes the cardiac murmurs 
of mitral disease may be heard distinctly over a considerable 
portion of the cardiac region and at the back. The murmur 
varies in intensity, is increased from slight exertion, as change 
of position, especially from the horizontal to the vertical. A 
soft, sometimes presystolic, murmur is occasionally heard ; in 
cases of extreme mitral insufficiency with great hypertrophy of 
both ventricles, loud and blowing murmur during systole. "An 
important sign on auscultation is the accentuated pulmonary 
second sound. This is heard to the left of the sternum in the 
second interspace, or over the third left costal cartilage" 
(Osier). 

Osier emphasizes the following as the three important phys- 
ical signs of mitral regurgitation: (a) systolic murmur of max- 
imum intensity at the apex, which is propagated to the axilla 
and heard at the angle of the scapula; (b) accentuation of the 
pulmonary second sound ; (c) evidence of enlargement of the 
heart, particularly the increase in the transverse diameter, due 
to hypertrophy of both right and left ventricles. 

Diagnosis. — The diagnosis can usually be made without 
much difficulty. It must be remembered that often the history 
of the case is quite as valuable as the physical signs. Thus, the 
systolic murmurs above described are not entirely limited to 
mitral insufficiency, neither are they always sufficiently distinct 
to make differentiation between them and similar murmurs an 
easy task. Murmurs of haemic origin may be mistaken for 
those due to mitral insufficiency, although they are softer and 
"musical," and more sharply localized; the expulsion of air 
from that portion of the lung which overlaps the heart pro- 



1070 DISEASES OF THE ORGANS OF CIRCULATION. 

duces a similar murmur, which is increased in volume after a 
full inspiration ; an aneurismal murmur may cause embarrass- 
ment, and be recognized as such only from its following the 
aorta downward and from its being lost gradually instead of 
terminating abruptly. Complication of sounds also may exist 
and confuse ; thus, as pointed out b}' Camman (Loomis, Phys- 
ical Diagnosis) there maj^ be an aortic obstructive systolic, 
with aortic regurgitant diastolic extending to the apex with 
the mitral regurgitant behind without a corresponding mur- 
mur in front. Idiopathic dilatation and hypertrophy of the 
heart and arterio-sclerosis with dilated heart present especial 
difficulties of differentiation from mitral incompetency. 

MITRAL STENOSIS. 

Mitral stenosis or narrowing of the mitral orifice ranks next 
to mitral insufficiency in the frequency of its occurrence. Very 
rarely it is congenital ; in many cases no immediate cause can 
be found ; but in the majority of cases it is the outcome of val- 
vular endocarditis, usually dependent upon rheumatism, fre- 
quently subacute, or of chorea. It is more common in early 
life, and occurs oftener in women than in men. It frequently is 
associated with mitral insufficiency. 

Morbid Anatomy. — The narrowing of the mitral orifice is due 
to thickening and contraction of the tissues composing the seg- 
ments, chordae tendineae and ring or to calcareous infiltration 
of the ring, which may in large masses project into the curtain. 
The thickening and shortening of the chordae tendineae may be 
so extensive that the papillary muscles are inserted directly 
upon the valve. The shape and extent of the narrowing differs. 
A common form is the "funnel-shaped" variety, in which the 
deformity is the result of gradual adhesion at the edges and 
thickening of the chordae tendineae, the valve assuming the 
shape of a rigid funnel which projects into the ventricle, with 
the orifice just sufficiently constricted to barely admit the tip of 
a finger. In other cases the orifice is "slit-like" (Corrigan's 
button-hole constriction). The changes in the heart are char- 
acteristic. Obstruction to the passage of the blood into the left 
ventricle results in dilatation of the left auricle with compara- 
tively great lrypertrophy ; this distension of the left auricle 
leads to pulmonary congestion and tension ; to overcome this, 



MITRAL STENOSIS. 1071 

hypertrophy of the right ventricle becomes a logical necessity. 
Eventually the dilatation of the right ventricle is so great that 
the tricuspid valve can no longer close the orifice (relative in- 
competency) and congestion of the systemic veins (general cya- 
nosis) results. The labor of the left ventricle in a case of pure 
stenosis is often sufficiently reduced to result in atrophy ; if mi- 
tral insufficiency exists with stenosis, a moderate degree of hy- 
pertrophy may be observed. Congestion of the pulmonary ves- 
sels, followed by important secondary changes (sclerosis), is 
highly characteristic of mitral stenosis. Thrombi are some- 
times found in the left auricle. 

Symptoms. — Since compensation may be maintained for 
years, no marked symptoms occur in the earlier course of mi- 
tral stenosis. The pulse, though usually small, is regular; 
breathing becomes somewhat labored upon exertion. There is, 
however, during this stage considerable danger from recurring 
attacks of endocarditis and from the results which follow the 
accidental entrance of a ' 'vegetation " into the circulation. 
Failure of compensation is characterized by the same group of 
serious symptoms which is associated with failure of compen- 
sation in mitral insufficiency. A marked feature in mitral ste- 
nosis is the grave results of an incidental pleuritis or pneumo- 
nia, to which the existing pulmonary engorgement creates a 
special liability. General dropsy during the last stage is not so 
common as in mitral incompetency, but there is frequently, 
especially in children, great enlargement of the liver with ascites. 

Physical Signs. — Inspection. Evidence of enlargement. The 
apex beat is not exaggerated. Pulsations in the epigastrium. 
After failure of compensation, feebleness of the precordial im- 
pulse; often systolic regurgitation in the jugular veins. — Palpa- 
tion. The peculiar "thrill" elicited by palpation constitutes one 
of the most reliable signs. It is the result of the vertiginous 
currents in the blood, and usually is felt best in the fourth or 
fifth interspace within the nipple line. It is variously described 
as of rough, grating quality or like a prolonged " cat's purr " ; it 
is presystolic, not constant, but, when present, highly diagnos- 
tic. The cardiac impulse is that of the right ventricle ; it is felt 
most forcibly in the lower sternum, and grows very weak when 
dilatation of the right ventricle has become great. The radial 
pulse is small and often very irregular. — Percussion. Increase 



1072 DISEASES OF THE ORGANS OF CIRCULATION. 

of cardiac dulness toward the right, reaching to the right bor- 
der of the sternum, and beyond it ; if there is much enlargement 
of the right auricle, the area of dulness is extended upward. 
Collapse of pulmonary tissue or enlargement of the left heart, 
or displacement of the heart to the left, correspondingly affect 
the area of dulness. — Auscultation. The presystolic murmur is 
characteristic. It is a vibratory, prolonged, murmuring sound, 
heard at the inner side of the apex beat and transmitted only 
slightly toward the base ; in exceptional cases this murmur is 
heard far toward the left. It is caused by the vertiginous cur- 
rents set up in the blood as it is forced through the constricted, 
narrowed valvular opening, and, compared with the systolic 
murmur of mitral insufficiency, is less " blowing " and more roll- 
ing or "rippling." It is in reality diastolic, but since it con- 
tinues until the systolic contraction occurs, the term "presys- 
tolic" is commonly used. When the dilatation of the heart is 
sufficiently great to rob the diastole of due energy, this sound 
is no longer produced. Sometimes it is absent throughout. 
Another sign of much value is the sharpness and clearness of 
the first sound following the presystolic murmur ; its cause has 
not been satisfactorily explained ; it may be heard when there 
is no presystolic murmur. "The second sound at the pulmonic 
cartilage is loud and often ringing in character. Reduplication 
of the second sound is much more frequently noted than that 
of the first, and it has, therefore, a definite amount of diagnos- 
tic value" (Pepper). These signs fail as soon as the compensa- 
tory effort of the heart ceases. 

AORTIC INSUFFICIENCY. 

Aortic insufficienc3 r occurs in from 30 to 50 per cent, of all 
valvular disease of the heart; it arises from disease of the valve 
segments or is the result of an abnormally large orifice which 
the smaller valve cannot close (relative insufficiency). 

The aetiology embraces: Congenital malformations, as fusion 
of the segments ; compensation may here be indefinitely main- 
tained, but constant danger arises from sclerotic endocarditis. 
Distinctive changes, such as occur in the course of endocarditis; 
in the absence of such changes, (simple) endocarditis does not 
usually affect the aortic valve. More often aortic incompetency 
results from long-continued and severe strain put upon the 



AORTIC INSUFFICIENCY. 1073 

heart, as in running, rowing, and other sports ; hence it is fre- 
quently called the "athlete's heart." Alcoholism and syphilis 
are also active factors; rheumatism is less important here than 
in mitral disease. The affection is seen oftener in men than in 
women, and belongs chiefly to middle age (fifth decade of life) ; 
cases of rheumatic origin occur oftener in the young. 

Morbid Anatomy. — The valve itself is contracted, puckered, 
curled at the free edge ; even slight "curling" may cause consid- 
erable incompetency. Gradually developing sclerotic changes 
give rise to rigidity of the structure, which may be rendered 
still more useless by calcification. There may be adhesion of 
the valve segment to the aortic intima and ulceration or rup- 
ture (trauma) of a segment, each sufficient to cause incompe- 
tency. The imperfect closure of the aortic valves allows a re- 
turn current of blood from the aorta into the left ventricle ; 
hence dilatation of the left ventricle and eventually hypertro- 
phy. These here are very great ; the papillary muscles are often 
completely flattened; the heart may reach an enormous size, 
Weighing from thirty-five to forty ounces, and even more (cor 
bovinum). The mitral valves are rarely seriously affected, but 
relative mitral incompetency is not infrequent. Dilatation and 
hypertrophy of the left auricle usually occurs, and dilatation of 
the right ventricle is likely to supervene in cases of long stand- 
ing. There is also interstitial myocarditis, localized or diffuse, 
followed by fatty degeneration. The arch of the aorta, more 
especially its ascending portion, is dilated and its intima scle- 
rotic and atheromatous ; the coronary arteries also may be 
atheromatous or their orifices occluded by atheromatous de- 
posits, and these constitute important factors in producing the 
degenerative changes in the heart itself. Sclerosis of the arte- 
rial system is a marked feature and is attributed to the strain 
put upon the vessels during each forcible ventricular systole. 
Strong pulsations are felt even in the smaller and peripheral 
arteries of the body, and sometimes an arterial pulse may be 
felt in the liver through the abdominal -wall. A peculiarity of 
the pulse in incompetency of the aorta is its rapid decline (Cor- 
rigan's pulse ; pulsus celer). The large amount of blood thrown 
by the left ventricle into the arterial circulation gives to the 
pulse great force and high "ascent ;" but the escape of blood, at 
the next ventricular diastole, into both the capillaries and back 
68 



1074 DISEASES OF THE ORGANS OF CIRCULATION. 

into the ventricle, causes a very rapid and deep decline of the 
pulse, thus giving to the pulse of aortic insufficiency its pecu- 
liar "jumping" or "springy" quality. In very marked cases 
this backward wave makes itself felt even in the capillary cir- 
culation, and there may be noticed in such cases decided pallor 
of the finger nails at every diastole of the heart (Quincke's cap- 
illary pulse). 

Symptoms. — In uncomplicated aortic insufficiency, especially 
in cases which follow endocarditis, compensation may be main- 
tained for years and the patient enjoy good general health and 
be able to endure a fairly large amount of physical exertion. 
Struempell points out that in these cases the complexion is us- 
ually normal or pale, unlike the slightly cyanotic hue of mitral 
disease. If mitral incompetency is added, serious disturbances 
result earlier. As soon, however, as arterial sclerosis and 
changes in the myocardium take place, constitutional symp- 
toms arise, usually with palpitation, increasing dyspnoea from 
exertion, headache, dizziness, flashes of light, faintness when 
rising quickly, anaemia, restlessness at night, inability to sleep 
when tying down, cough with occasional haemoptysis, oedema 
in the feet, occasionally general dropsy, increasing weakness, 
with, toward the close, slight irregular fever, often with recur- 
ring endocarditis, death usually taking place suddenly. Com- 
pared with other valvular diseases, there is in aortic insuffi- 
ciency a greater tendency to pain at the heart, even before fail- 
ure of compensation ; this pain is sometimes dull and aching, 
again sharp and lancinating, extending into the neck and (left) 
arm, and closely resembling attacks of true angina. Cough is 
very frequent and persistent, but haemoptysis is not common 
as in mitral disease. There is a remarkable tendency to dis- 
tressing dreams and anxious sleep. General dropsy is compar- 
atively infrequent in uncomplicated cases. Toward the close of 
life the mental symptoms are pronounced, and delirium, hallu- 
cinations and morbid impulses, often of a homicidal character, 
are not uncommon. Sudden death occurs oftener here than in 
any other valvular disease. 

Physical Signs. — Inspection. Protrusion in the cardiac re- 
gion from the excessive hypertrophy of the left ventricle, most 
marked in the young. Strong, heaving apex beat, displaced 
downward and toward the left, at the sixth or seventh inter- 



AORTIC INSUFFICIENCY. 1075 

costal space and between the left mamillary and anterior axil- 
lary line. Often diffused, heaving tremor of the cardiac region. 
Violent pulsation of the cervical vessels and of even superficial 
vessels. Quincke's ''capillary pulse ;" alternate "blushing" and 
"paling" on gently pressing a finger-nail or on rubbing the fore- 
head. — Palpation. Evidence of cardiac enlargement. Apex 
beat massive, heaving. — Percussion. Remarkable extension of 
cardiac dulness to the left, beyond the left mammillary line, and 
downward ; also to the right, if the enlarged left ventricle has 
pushed the heart to the right or if the right ventricle also is en- 
larged. Moderate degree of dulness over the dilated aorta (at 
external end of second right intercostal space). — Auscultation. 
Long-drawn, distinct, but soft, blowing diastolic murmur to 
the left of the external end of the second right intercostal space 
over the upper part of the sternum. It is rarely absent. Occa- 
sionally it possesses a distinct musical quality and pitch, 
thought to be due to the vibrations during the diastolic move- 
ment of a tendinous fibre, the result of the wearing away of a 
valve. It is sometimes faintly audible at the apex. A short, 
rather rough, systolic murmur is often heard over the aorta, 
especially in case of aortic stenosis ; it often is propagated into 
the neck. This is by some assigned to the roughness of the 
valve segments and of the intima of the arch, and by others to 
the fact that the current of blood from the left ventricle into 
the aorta meets and must overcome the backward current from 
the aorta through the incompetent valve. In case of extensive 
dilatation of the left ventricle with dilatation of the orifice and 
relative mitral insufficiency, a second murmur, rumbling in 
quality, limited in area, and exactly presystolic in time, is 
heard. It -was first described by Flint, who attributes its oc- 
currence to the fact that during diastole of the greatly dilated 
ventricle the valve segments cannot be pressed close back 
against the wall, but remain in the blood current, causing a 
certain amount of narrowing and the vibratory murmur de- 
scribed. 

The importance of the visible pulsations in the arteries has 
already been mentioned. This pulsating motion of even the 
peripheral vessels partakes of a "jerking" character and may, 
by the ophthalmoscope, be sden in the arteries of the retina ; 
pulsations are also noticed in the peripheral veins. The so- 



1076 DISEASES OF THE ORGANS OF CIRCULATION. 

called Corrigan's pulse has been described. "The pulse wave 
strikes the fingers forcibly with a quick jerking impulse, and 
immediately recedes or collapses. The characteristics of this 
are sometimes best appreciated by grasping the arm above the 
wrist and holding it up." A double murmur may be heard in 
the carotids and subclavians when it exists at the aortic orifice; 
the same occurs in the femoral artery, upon pressure. 

AORTIC STENOSIS. 

A rare affection, as compared with aortic incompetency. It 
maj r occur in the young as the result of union of the leaflets 
from rheumatic endocarditis, but commonly is found in old age, 
especialry in men, in connection with extensive atheromatous 
changes in the arterial system. The valve segments in the 
milder form are adherent and stiff, with only slight thickening 
and few traces of sclerosis or atheroma ; in more se\ r ere cases 
they are hard, like cartilage; if the disease is well advanced, 
they become a hard calcified mass which obstructs the orifice 
and permits the passage of blood by a roundish or slit-like 
opening. The term "relative stenosis" is used to describe a 
considerable dilatation of the aorta beyond the normal ring 
and valves. 

Only a slight dilatation of the left ventricle occurs when the 
case develops gradualky and incompetency is trifling. Eventu- 
ally there may be marked hj-pertrophy of the wall of the left 
ventricle, but the chamber itself is not correspondingly enlarged 
("concentric hypertrophy"). Later dilatation takes place, 
with thickening of the mitral A r alves, relative insufficiency, and 
dilatation and hypertrophy of the left auricle. Pulmonary 
congestion eventually results and increases the tendency to hy- 
pertrophy. Arterial changes occur, chiefly in the arch of the 
aorta, with, often, narrowing of the orifices of the coronary 
arteries and subsequent degeneration of the heart ; but these 
changes are by no means as marked as those of aortic insuffi- 
ciency. 

Physical Signs. — Inspection. The apex beat is displaced 
downward, according to the degree of hypertrophy of the left 
ventricle ; the slowed contraction of the ventricle and the ab- 
sence of the backward impulse renders the beat weak. The 
pulse is small, weak, hesitating, but in the majoritj^ of cases 



TRICUSPID INSUFFICIENCY. 1077 

regular. — Palpation. Frequently a thrill is heard at the base 
of the heart, in the region of the aorta ; when present, it is 
highly characteristic. — Percussion. Extension of the area of 
dulness to the left. — Auscultation. A "sawing," long-drawn 
systolic murmur may be heard over the aorta, most distinct at 
the sternal end of the second intercostal space; it is propagated 
into the great vessels (aorta, carotids) and may be diffused 
over a large portion of the region of the heart. It, however, is 
not pathognomonic, since other conditions (roughening of the 
valves or aortic intima, haemic states) may cause it. The 
aortic second sound often is feeble or wholly lacking. If there 
is marked incompetency of the valve, a diastolic murmur may 
or may not be heard. 

The early constitutional symptoms are those of cerebral 
anaemia, as dizziness and fainting. Palpitation and pain at the 
heart may be present to a moderate degree, but do not in se- 
verity compare with those of aortic incompetency. Epileptic 
seizures may occur. In old people the symptoms are often 
those of disease of the arteries. Compensation having failed, 
the usual symptoms of advanced valvular disease are present. 
Generally speaking, the course of aortic stenosis is more unfav- 
orable than that of aortic incompetency, but more favorable 
than that of mitral stenosis. 

TRICUSPID INSUFFICIENCY. 

Insufficiency of the tricuspid valve results from endocarditis 
or is relative ; in the latter case the difficulty arises from an in- 
creasing dilatation of the right ventricle which prevents the 
meeting of the normal edges of the tricuspid valve. Organic in- 
sufficiency of the tricuspid may occur in fcetal life, and is com- 
paratively frequent in early infancy, growing more rare with 
advancing years. Relative incompetency is often secondary to 
disease of the mitral valve and to such conditions of the lungs 
as interfere with the pulmonary circulation (cirrhosis, emphy- 
sema, phthisis, chronic bronchitis). Tricuspid insufficiency in 
itself causes dilatation and hypertrophy of the right ventricle 
from the increased influx of blood into the right ventricle dur- 
ing diastole. Much more important, however, is the backward 
current which during every systole passes through the open tri- 
cuspid valve into the right auricle and from there into the ve- 



1078 DISEASES OF THE ORGANS OF CIRCULATION. 

nous circulation. The supply of blood to the pulmonary arte- 
ries, and the tension within them, is materially lessened. The 
more important S3'mptoms are cyanosis, dropsy and those 
changes in the urine which pertain to valvular disease, often 
associated with disturbances of the respiratory organs. The 
symptoms of the associated lesions are, however, the most con- 
spicuous. Gradual failure of the heart, with cardiac dropsy, or 
acute as3'stole may occur in cases complicated with cirrhosis 
of the lung or chronic emphysema. 

Physical Signs. — The pathognomonic signs of tricuspid incom- 
petency are the so-called venous pulse and the occurrence of a 
systolic murmur which is of maximum intensity in the lower 
sternum. The "venous pulse" arises from systolic regurgita- 
tion of blood into the right auricle, and assumes characteristic 
distinctness as soon as the valves guarding the veins become 
incompetent ; its strength depends also upon the amount of re- 
gurgitating blood and upon the force of the ventricular con- 
tractions ; if the latter are slight, the venous pulsation is, of 
necessity, faint. The jugular vein, especially on the right side, 
most distinctly shows this pulsation, and may be enormously 
distended, especially during the act of coughing. It is, how- 
ever, no infrequent occurrence to see the pulsation transmitted 
to the subclavian and axillary or to smaller, superficial veins. 
In many cases the pulsation ma)- be felt in the liver by placing 
one hand over the fifth and sixth intercostal cartilages, the 
other in the lateral region of the liver, in the mid-axillary line ; 
the latter may even be heard when the jugular venous pulse 
cannot be felt, because the veins in the liver have no valves. 
The murmur over the lower part of the sternum arises from the 
regurgitating blood current. It is rather soft and low, extend- 
ing over an area of distribution which varies greatly, sometimes 
being limited, while in other cases it may be heard high, toward 
the axilla, on the right side. 

TRICUSPID STENOSIS. 

This form of valvular disease occurs almost always in con- 
nection with disease of other valves, especially affections of the 
left heart. Clinicians differ as to its frequency, but all admit 
that it is rare as an isolated affection. The physical signs are 
great dilatation of the right auricle and a diastolic or presys- 



PULMONARY INSUFFICIENCY. 1079 

tolic murmur over the right side of the heart, notably at the 
root of the ensiform cartilage or slightly to the right of it. 
The symptoms are chiefly those of marked cyanosis of the face 
and lips, especially pronounced after the supervention of 
dropsy. 

PULMONARY INSUFFICIENCY. 

A very rare affection which may be congenital (usually 
union of two of the segments) or the result of endocarditis 
after birth. Relative insufficiency is seen in connection with 
aneurism of the pulmonary artery. It is followed by dilatation 
and hypertrophy of the right ventricle and, in case of excess- 
ive dilatation, is complicated with tricuspid insufficiency. 

The physical signs are very uncertain, being practically those 
of regurgitation into the right ventricle, and scarcely to be dis- 
tinguished from the murmur of aortic insufficiency, "though the 
enlargement of the right ventricle, the establishment of tricus- 
pid insufficiency and early cyanosis, and the absence of the 
water-hammer pulse would furnish strong indications of pul- 
monic disease. In addition, it is to be noted that the pulmon- 
ary murmur is loudest to the left of the sternum, the aortic to 
the right" (Pepper). 

PULMONARY STENOSIS. 

A very rare affection, usually congenital and associated with 
inflammation of the heart or fcetal endocarditis. Occasionally 
cases occurring after birth have been recorded, showing union 
of the segments, with thickening, great narrowing of the orifice, 
and the vegetations of acute endocarditis. Compensation is 
maintained by hypertrophy of the right heart. The physical 
signs are exceedingly unreliable. There may be a systolic thrill- 
ing murmur, which is most distinct in the second interspace, to 
the left of the sternum, and not transmitted into the vessels. 
The pulmonary second sound is weak or replaced by a diastolic 
murmur. 

The Symptomatology of the Valvular Lesions. — While com- 
pensation is maintained, little, and often no, complaint is made 
by the patient ; this applies especially to incompetency of the 
aortic valve, much less to mitral insufficiency. In other cases 



1080 DISEASES OF THE ORGANS OF CIRCULATION. 

some slight difficulty^ of breathing is experienced or the physi- 
cian may be consulted in regard to some minor but persistent 
ailment, without reference to the heart, and the true nature of 
which may not be suspected at this time. Later, dyspnoea in- 
creases, not in itself seriously annoying, but made much 
worse from slight physical exertion, a sudden start, or from 
nervous excitement ; in mitral insufficiency this is an early and 
persistent symptom. There is also a sense of discomfort about 
the heart, with some irregularity of the pulse, and occasionally 
slight pain. As the compensatory power of the heart is weak- 
ened, there is increasing tendency to palpitation, irregularity of 
action, difficult breathing, more frequent and severe pain. 
Failure of compensation finally occurs from advanced disease 
of the valves, arterial disease, or failure of the heart's nutrition 
with resulting degeneration. It usually develops gradually > 
but may prove rapidly progressive when an acute infectious dis- 
ease (typhoid fever, diphtheria, "la grippe") attacks a person 
suffering from valvular disease or if severe and prolonged 
strain is put upon the heart. Then the subjective symptoms 
promptly assume a serious aspect. The patient suffers from 
severe palpitation, sense of weight, pressure and constriction in 
the chest, and cardiac pain which in many cases partakes of 
the character and severity of an angina pectoris. The pulse 
becomes habitually rapid and irregular in the great majority 
of cases; dyspnoea steadily increases, and finally proves a 
source of constant and great distress. Failure of circulation 
shows itself in the duskiness of the complexion and cyano- 
sis of the surface of the body ; the inner organs suffer from 
stasis; dropsy develops, and the general health fails as the re- 
sult of the widespread mischief arising from the heart lesion. 

Dyspnoea is by all means the most distressing and constant 
subjective symptom. It may be present early in the case, and 
in disease of the mitral valves is particularly pronounced 
throughout. It deprives the patient of rest during the day and 
seriously disturbs his sleep at night, frequently obliging him to 
pass his time in an erect posture, even to get sleep, and some- 
times assumes the form of a veritable "cardiac asthma" which 
may recur for years at irregular intervals. It depends upon a 
combination of causes, of which the most important are: ob- 
structed pulmonary circulation ; rigidity and lack of expansi- 



PULMONARY STENOSIS. 1081 

bility of the pulmonary tissue, most marked in the advanced 
cases with cyanotic induration; great tension in the pulmonary 
circulation; oedema; compression of the lungs from hydro tho- 
rax or largely dilated heart ; hemorrhagic infarctions. Cheyne- 
Stokes breathing — alternating periods of breathing with pe- 
riods of cessation of breathing — is frequently a feature of the- 
last stage, particularly in cases with severe renal complica- 
tions ; it is more common in aortic disease and when there is 
degeneration of the myocardium. The Heart. The heart's ac- 
tion is usually somewhat accelerated and easily excited by tran- 
sient causes. Sometimes it is regular to the last. An irregular 
pulse is more common in mitral disease ; permanent slowing 
and infrequency is more often seen in aortic stenosis. Increas- 
ing irregularity of the pulse is a sign of failing compensation. 
A careful estimate of the value of the pulse beat demands that 
the ear be kept on the heart while the finger is at the wrist and 
that sphygmographic tracings be taken. Tachycardia, a sud- 
denly appearing enormous acceleration of the pulse to 200, or 
more, beats per minute, accompanied with palpitation and dis- 
tress, lasting for several hours and disappearing suddenly, is 
occasionally seen in mitral disease. Pain at the heart varies 
from a dull pain with a sense of fulness or oppression to a true 
angina ; the latter occurs oftener in aortic than in mitral dis- 
ease. It is relieved by rest. It is commonly associated with 
atheromatous disease of the valves and arteries (especially of 
the aorta), with high tension within the arteries and ventricles 
and degeneration of the myocardium. Pericarditis sometimes 
occurs as a dangerous complication. 

The Effects of Stasis. — One of the first symptoms indicating a 
disturbed venous circulation is a cyanotic appearance of the 
skin, showing itself especially in mitral disease in slight duski- 
ness of the lips, ears, alae nasi, cheeks and finger tips ; in young 
subjects the face often is materially changed, the lips appearing 
thicker, the nose broader and heavier, and the complexion 
dusky ; the finger ends are bulbous and the nails curve in ; in 
older persons a fine net work of distended vessels may be seen 
on the nose, cheeks or extremities. In aortic disease there may 
be pallor, until mitral insufficiency becomes great. CBdema 
soon appears, beginning at the feet and creeping upward ; it is 
common in mitral disease, rare in aortic disease without mitral 



1082 DISEASES OF THE ORGANS OF CIRCULATION. 

incompetency. At first it appears only temporarily, perhaps 
during the day, to disappear at night, but later it becomes per- 
manent, transudation taking place into the abdominal, pleural, 
and other serous cavities. Pulmonary stasis is largely respon- 
sible for the dyspnoea of valvular disease. Cough is frequently 
present, especially when there is a tendency' to chronic bron- 
chitis, with watery and sometimes copious expectoration con- 
taining pigment matter from extravasated blood. Bleeding 
(stenosis of the mitral valve) may result if the congestion is 
great, and then affords decided temporary relief. Congestion 
of the Liver is followed by great enlargement of the organ, 
sometimes with pain ; in some cases atrophy of its cells event- 
ually occurs, and then the enlargement disappears. Moderate 
jaundice is frequent. Cyanotic induration of the liver may oc- 
cur, offering serious obstruction to the portal circulation. The 
enlargement is greatest in tricuspid disease, and the jaundiced ap- 
pearance of the skin most striking in mitral disease, on account 
of its mixture with the distinctly cyanotic hue. Congestion of 
the Spleen, with enlargement of the organ, felt under the edge 
of the ribs on the left side, occurs late. Congestion of the Kid- 
neys is recognized by pain in the back and urinary changes. 
The urine is lessened in amount, of dark color and of high spe- 
cific gravity, contains urates and albumin if the congestion is 
very marked. There may be acute or chronic nephritis. Con- 
gestion of the Gastric and Intestinal Mucous Membrane is char- 
acterized by catarrh of the mucosa, and is frequent in disease 
of the mitral valve. 

Embolic Processes.— In the lungs : great and rapidly increas- 
ing dyspnoea, pain in the chest, hemorrhagic sputa, extensive 
dulness, with weakened respiratory' sounds and liquid rales. — 
Cerebral Arteries: transient disturbances of consciousness, 
palsy, apoplexy with permanent hemiplegia ; sometimes epi- 
lepsy. — Arteries of the Leg (femoral and brachial) : Coldness, 
blueness and blackness of the periphery of the affected part, 
with excruciating pain, gangrene and necrosis. The complica- 
tion is rare and exceedingly serious, partly because of its effect 
upon the vital forces, partly because of the danger arising from 
septicaemia. — Kidneys: Sudden severe pain in the loins, with 
haematuria. — Spleen: Perisplenitic pain and swelling; some- 
times no symptoms. — Intestines: Embolism of the mesenteric 



PULMONARY STENOSIS. 1083 

artery is rare. Sudden abdominal pain, intestinal haemorrhage, 
rapidly developing collapse. Small embolisms of the skin may 
produce petechial eruptions. Thrombosis of the veins is fol- 
lowed by great distension, oedema and intense pain. Thrombi 
of curious shape have been found in both the auricles and ven- 
tricles of the heart. 

The nervous system is affected oftener in aortic than in mi- 
tral disease, presumably the result of the impairment of nutri- 
tion from the circulatory disturbances set up by atheromatous 
degeneration. The symptoms most likely to be experienced are : 
vertigo and tinnitus aurium, especially from suddenly assuming 
an erect posture and from exertion ; sudden faintings ; severe 
headaches of a neuralgic character ; restlessness and insomnia ; 
psychoses, as melancholia, with suicidal tendency. Death in 
cases with a predominance of nervous symptoms is usually pre- 
ceded by delirium, stupor and coma, with Cheyne-Stokes respir- 
ation. 

The general symptoms present nothing characteristic, and 
the general health often is remarkably good. Fever is rare, 
save as it is connected with recurring endocarditis or some 
other complication. Secondary affections of the joints are 
sometimes seen, and a tendency to haemorrhage, other than 
those noticed, has been observed. Thus epistaxis is not uncom- 
mon, especially in mitral stenosis ; again, haematemesis and ex- 
cessive menstrual flow occasionally occur. 

Complications. — Irregularly recurring attacks of acute endo- 
carditis, especially of the malignant form, are dangerous and 
should be suspected upon the sudden accession of fever. — Peri- 
carditis may complicate any stage, but occurs oftener in aortic 
than in mitral disease. In the young it is not infrequently as- 
sociated with endocarditis. —Arterial Sclerosis is common 
and serious, and may be the direct cause of degenerative 
changes not only involving the kidneys and other inner organs, 
but the heart itself. — Nephritis (uraemia), pleurisy, pneumonia 
(hypostatic), chronic bronchitis, cedema of the lungs and ca- 
tarrhal inflammation of the gastric and intestinal mucous 
membrane may occur and unfavorably affect the course of the 
valvular disease. 

Course and Prognosis. — The course of all valvular diseases is 
thoroughly chronic, and life, in the absence of complications, 



1084 DISEASES OF THE ORGANS OF CIRCULATION. 

may be indefinitely prolonged. Sudden death from valvular 
disease is by no means as common as is supposed by the un- 
informed, neither are the people suffering from it incapacitated 
from participation in the common duties and pleasures of life 
so long as the}' are prudent and avoid excess in living, severe 
exposure to inclemencies of weather, and violent exercise or 
great muscular exertion. Unfavorable conditions are: great 
C3'anosis ; special liability to catarrhal or rheumatic affections; 
tendency to disease on part of the blood-vessels ; the occur- 
rence of acute infectious diseases ; lesions of the pulmonary tis- 
sues; marked congestion of the internal organs, especially 
of the lungs, liver and kidneys. Sex and age somewhat affect 
the prognosis. In women, all things considered, valvular 
disease runs a more protracted and favorable course than in 
men, chiefly because the latter are more constantly exposed to 
the operation of unkindly influences. Pregnancy and labor un- 
doubtedly present dangers of their own in case of valvular af- 
fection, but such women often rear a large family of children 
and live an active life. The liability of severe strain upon the 
heart during severe labor is great, and its effect depends upon 
the existing degree of compensation. Children less than ten 
years old constitute a bad class of patients, since in them 
valvular lesions seem to progress with great rapidity and ex- 
cessive hypertrophy and dilatation ; this tendency is much less 
pronounced if the disease appears at or near the age of pu- 
berty. The unfavorable conditions which surround the children 
of the poor greatly increase the probability of a fatal termina- 
tion. All things considered, the value of the prognosis here rests 
upon a careful estimate of all the conditions surrounding each 
individual case, with due allowance for complications, such as 
are liable to arise at any time. Compensation is usually more 
permanently and completely effected in insufficiency of the 
mitral and aortic valves than in stenosis. Tricuspid insuffi- 
ciency is so largely the result of failing compensation in mitral 
disease that its recognition makes the prognosis grave ; in ste- 
nosis of the tricuspid Fenwick's table of 46 cases shows a dur- 
ation of life of from 31 to 36 years. Mitral insufficiency runs a 
long course, and a high grade of compensation is often main- 
tained for 30 to 40 years, with ability to perform all the com- 
mon duties of life. The course of the affection is, however, ex- 



PULMONARY STENOSIS. 1085 

ceptionally rapid in children, and examination after death 
shows that there is usually extensive puckering and curling of 
the segments, thus forming a narrow strip around a wide mi- 
tral ring. In mitral stenosis special danger exists of cerebral 
embolism. In aortic insufficiency the prognosis is very serious, 
and sudden death may occur from acute dilatation during a 
violent exertion or from blocking of one of the coronary arte- 
ries. 

The prognosis is good, as to duration of life, if the dilatation 
and hypertrophy are moderate, if there is slight or no cardiac 
distress, and in the absence of arterio-sclerosis or involvement 
of the coronary arteries. 

Treatment of Valvular Disease. — The treatment of valvular 
disease divides itself into (1) such measures as during the stage 
of compensation will prolong this condition of comparative 
safety and comfort, and will prevent, so far as possible, any 
act on part of the patient which will break compensation ; (2) 
such measures, when compensation is broken, as will reduce 
existing danger to life, support the heart, and relieve special 
symptoms and danger. Throughout, the necessity of preserv- 
ing the muscular tone of the heart is evident. To accomplish 
this, it may be necessary to insure the intelligent cooperation 
of the patient by frankly informing him of his condition and 
pointing out the fact that his fate is largely in his own hands. 
In making this statement, candor must be tempered by good 
judgment and gentleness of speech, lest well-meant and neces- 
sary advice do more harm than good by leaving upon the mind 
of the patient the conviction that he is doomed. It is a task 
of much delicacy, and in attempting to perform it the strongest 
possible emphasis is to be placed upon the fact that the exer- 
cise of patience and sound judgment may not only prolong life 
and usefulness beyond the average, but ma3' result in what is 
almost equivalent to a cure. It is evident that everything 
likely to weaken the heart must be avoided, and that every- 
thing likely to strengthen it must be done with religious perse- 
verance. Over-exertion and indolence are alike dangerous, the 
ormer from the immediate harm it may do, the latter from the 
mischief sure to arise indirectly. A moderate amount of well- 
regulated exercise is absolutely necessary to maintain a needful 
degree of muscular energy, of the heart no less than of any 



1086 DISEASES OF THE ORGANS OF CIRCULATION. 

other muscle; in fact, excellent results in the treatment of valv- 
ular disease have been obtained by systematic exercise with the 
sole view of developing increased muscular force of the heart. 
As a general rule in these cases, moderation in everything is of 
supreme importance. The patient must be made to thoroughly 
appreciate this ; a great point is gained if he can do so without 
becoming a hypochondriac. Thus he must guard against vio- 
lent physical exertion, must keep in check his emotions, and 
control his appetites. Stimulants, especially tobacco, have 
their dangers, 3 r et with due precaution need not be prohibited. 
Sexual indulgence, unless tempered with prudence, involves 
considerable risk in persons suffering from aortic insufficiency. 
Abundance of sleep is exceedingly helpful in that it not only en- 
ables the heart to rest, but allows it to accumulate and store 
muscular energy. Short baths in cool or tepid water are 
usually of benefit ; hot baths are less safe, and Turkish baths 
are absolutely forbidden. The bowels should be kept regular, 
and high altitudes must be avoided. A change of residence is 
frequently very desirable, if this provides for a life in the open 
air and at a low elevation. The exhibition of heart tonics at 
this stage is unnecessary and unjustifiable. 

The period of broken compensation makes heavy demands 
upon the resources of the most skillful physician. Rest is indis- 
pensable, and during the times of acute exacerbation which 
so frequently occur, or when acute dilatation has resulted from 
some accident, it must be absolute and prolonged. Experience 
has unquestionably proved that absolute rest alone may fully 
restore compensation. The embarrassment of the circulation 
which so quickly shows itself may be met by venesection, de- 
pletion through the bowels, or the exhibition of remedies which 
have a sustaining, stimulating action upon the heart. Vene- 
section is strongly recommended by Osier and other clinicians 
of large experience, especially in acute dilatation and cyanosis 
in connection with emphysema, the amount of blood to be 
withdrawn varying from twenty to thirty ounces ; others pre- 
fer leeching, and still others object to bleeding in any form and 
under all conditions. Depletion through the bowels is service- 
able in cases with dropsical tendency, and is insured by the 
administration, a half-hour, or more, before breakfast, of an 
ounce, or more, of Epsom salts in strong solution, as advised 



PULMONARY STENOSIS. 1087 

by Matthew Hay. The strength of the patient will determine 
how long this may safely be continued. Of remedies exhibited 
at this time the most important is Digitalis. It not only 
stimulates the heart-muscle, slowing its beat and increasing 
the force of its contraction, but also the activity of the circula- 
tion, and thus insures with equal efficiency the feeding of the 
heart muscle. It is useful in all forms of valvular disease dur- 
ing the stage of broken compensation, but is especially service- 
able in mitral disease, with small irregular pulse and cardiac 
dropsy. From ten to fifteen drops of a good tincture or one- 
half ounce of the infusion may be given every three hours for 
two days, with a reduction in the dose after that, in case of 
cardiac dropsy. If the drug acts well, the amount of urine 
passed will be materially increased in about twenty-four 
hours. It must be discontinued as soon as compensation has 
been reestablished. When there is no dropsy, smaller doses 
(from two to five drops every two to three hours) will exert a 
most desirable tonic action upon the heart muscle and answer 
every purpose ; but "attenuations " in the present case, where 
purely physiological effects are desired, lead to a reckless waste 
of time and of precious opportunities. Many recent authori- 
ties deny the cumulative action of Digitalis by the manifesta- 
tion of acute symptoms, but all admit that the drug is very 
slowly assimilated and eliminated. It should, therefore, never 
be given for a longer time than is necessary to reestablish the 
disturbed compensation, and its effects should be closely 
watched, especially if there is no increase of urine imder its ex- 
hibition; it must be promptly withdrawn if the pulse falls 
below 85 or 80. Toxic action usually manifests itself in 
nausea and vomiting, small and irregular pulse, great lessen- 
ing of the urinary secretion, and, especially in mitral stenosis, 
under the influence of Digitalis, the occurrence of two beats of 
the heart to one of the pulse (Broadbent). — Strophanthus in 
doses of five to ten drops, given at intervals of three or four 
hours, "steadies" the heart, and often does good work when 
Digitalis acts unsatisfactorily ; its chief value, however, lies in 
the fact that it is a good substitute for Digitalis when it 
becomes advisable to suspend the exhibition of the latter for 
the time being. Gottlieb is responsible for the statement, 
quoted by Whittaker, that he has never seen so many patients 



1088 DISEASES OF THE ORGANS OF. CIRCULATION. 

who have lived for years with heart disease die suddenly under 
any other treatment as after the use of Strophanthus. It 
should not be given to aged persons. Other important substi- 
tutes for Digitalis are: Convallaria, Adonis vernalis, 
Nerium oleander and Euonymus atropurpureus. Many 
practitioners deny the reliability of these "new" remedies, but 
hardly upon sufficient grounds. Convallaria is of especial 
value when there is much pulmonary congestion, dyspnoea 
and orthopnoea, associated with great mental irritability and 
excitement. Hale lauds it highly for its "marvelous" power 
to remove dropsy, save, perhaps, in cases with symptoms of 
albuminuria ; its use in Russia for dropsical affections is well 
known. It must be given in increasing doses, beginning with 
ten to twent3 r drops of the fluid extract every two hours. — 
Nerium oleander reduces the frequency of the respirations, 
gives to the pulse regularity and firmness, increases the secre- 
tion of urine and its solid constituents, and has a salutary 
effect upon the cedema, dyspnoea and palpitation of the heart ; 
it also regulates the action of the bowels. — Euonymus in- 
creases the power and the amplitude of the contractions of the 
heart, and, according to Hale, is especially useful when there is 
congestion of the liver and jaundice. — Adonis vernalis resem- 
bles Digitalis and Strophanthus. It increases arterial ten- 
sion and in large doses arrests the heart in diastole. Some- 
times it causes vomiting and diarrhoea, but only after large 
doses. The increase of arterial pressure is accompanied with 
an increased urinary flow. It has given proiupt relief in 
dyspnoea and cardiac dropsy. The tincture may be used in 
doses of five to ten drops every three or four hours, or the 
active principle, adonidin, may be exhibited in doses of gr. -^ to 
gr. i at the same intervals. 

By an intelligent use of these heart-tonics, of which Digitalis 
is by all means the most reliable, and especially by abstaining 
from their exhibition unless it is pointedly demanded and dis- 
continuing their use as soon as they are no longer needed, 
much may be accomplished in affording relief and in spinning 
out life. To these drugs Strychnia and Nux vomica should 
be added. Strychnia has less effect than previously named 
drugs upon the irregularity of the heart, but is a profoundly 
acting stimulant and tonic to the muscular fibre anywhere ; to 



PULMONARY STENOSIS. 1089 

act as such here, it must be given in drop-doses, or more, of a 
one per cent, solution. Other, and even more powerful, heart- 
stimulants may be used to meet special emergencies and will 
be discussed in their proper connection. 

Special Symptoms.— Palpitation and pain at the heart. The 
application of cold over the region of the heart usually relieves 
the throbbing and palpitation. Leiter's coils are in common 
use for this purpose, but a flask filled with ice water answers 
the purpose equally well. If there is much cardiac distress, 
Amyl nitrite (from two to four drops on a handkerchief, 
inhaled) or Nitro-glycerine (one to three drops of a one per 
cent, solution) may be exhibited; counter irritation (small 
blisters or mustard draughts over the heart) frequently an- 
swers the same purpose. In such cases careful attention must 
be paid to diet, with the view of excluding any article of food 
which may create flatulency. 

In very many cases the homceopathically indicated, attenu- 
ated remedy proves of inestimable value here. Those most 
frequently indicated are Amyl nitrite (3x): Tumultous action 
of the heart, with violent pulsation of the carotids ; sense of 
great anxiety and constriction in the cardiac region; great 
flushing and fulness of the face ; must have fresh air. — Arseni- 
cum. The heart's action is weak, irritable,* easily excited. 
Dropsical tendency. Intense oppression about the heart, with 
great difficulty of breathing; sense of tightness about the 
heart. Characteristic restlessness, great pallor, etc. — Asa 
Ecetida is of great value when the attacks of cardiac pain are 
associated with flatulency and, in women, with nervous symp- 
toms of a hysterical character. The heart's action is weak 
and rapid ; there is a sensation of trembling about the heart, 
with vague pressure and faintness. The cardiac pain often is 
severe, stitching. — Cactus. Palpitation, labored breathing, 
sense of suffocation, cold sweat ; cardiac dropsy. Sense of ex- 
cessive constriction about the heart, as though grasped in an 
iron hand or squeezed in a vise. — Digitalis (3x). Feeble, irreg- 
ular pulse, fluttering; sensation as if the heart would stop 
beating, and feeling of anxiety which compels him to draw in 
a long breath ; skin cold and pale. Cardiac dropsy. — Glono- 
Ine. Fluttering and violent beating of the heart ; it seems as 
though it would burst the chest; violent, labored action of the 
69 



1090 DISEASES OF THE ORGANS OF CIRCULATION. 

heart, with violent pulsations which are felt to the tips of the 
fingers ; cardiac pains radiate in every direction, even into the' 
arms. Faintness, weakness, trembling. — Lachesis. Palpita- 
tion ; sense of suffocation as though proceeding from an expan- 
sion of the heart ; sense as though the heart were turning over. 
Pain and numbness in the left arm. "It is extremely useful in 
atheromatous arteries and in chronic aortitis, with terrible 
dyspnoea" (T. F. Allen). Hypertrophy of the heart. Angina 
pectoris. — Oxalic acid. Sharp, short, stitching pains, con- 
fined to a small spot, .made worse from even the slightest 
motion ; palpitation, usually coming on from lying down at 
night ; numbness in the back and limbs. — Spigelia. Irregular, 
tumultuous action of the heart, with sharp, stabbing pain in 
the heart, extending into the arm ; great nervousness ; during 
recurring attacks of inflammatory action about the heart.— 
Tabacum. Dilatation; sense of extreme weakness of the heart- 
muscle; feeble and irregular pulse, deathly faintness, cold 
clammy sweat and sense of utter relaxation ; nausea and ex- 
treme "goneness;" the face is haggard and the extremities 
cold. Pains radiating from the centre of the chest. Tightness 
in the chest, with feeling of suffocation, especially at night. 

Dyspnoea frequently becomes so distressing that urgent de- 
mands for imme-diate relief cannot be ignored. It may be con- 
tinuous, with sharp parox3 r sms of exaggeration. If occurring 
nightly and associated with restlessness, morphia is highly 
recommended as prompt, reliable, and safe. Whittaker speaks 
earnestly of the beneficial action of quinine. In many cases the 
common cardiac stimulants act promptly. When there is much 
tension in the arterial system, nitro-glycerine in light, but in- 
creasing, doses of a one-per-cent. solution frequently* relieves. 
Convallaria has done good work in my hands ; amyl nitrite 
has proved of slight, if any, service. Chloroform, cautiously 
given, may afford rest and at least temporary relief. Cold 
compresses to the chest occasionally act well. When dyspnoea 
arises from oedema of the lungs, it is usually intensely distress- 
ing, and here caffeine is especial^* indicated, more particu- 
larly when there is scant}* secretion of urine from inactivit}* of 
the heart. It ma}* be given in light doses (gr. % to 1) at inter- 
vals of one or two hours ; in fact, small and frequently repeated 
doses of caffeine give the best results. Large doses of the 



PULMONARY STENSOIS. 1091 

citrate (grs. ,30 to 40 per day) have been well borne. Occa- 
sionally good results are obtained by a cupful of strong black 
coffee to which a teaspoonful of cognac has been added. — 
Diuretin (sodium salicylate theobromine) has of late been 
considered a valuable analogous preparation. Whittaker ad- 
vises its use "in cases of heart weakness marked by arhythmia 
and dropsy when digitalis has been used without effect or is cOn- 
tra-indicated for any cause." It affects the heart-muscle itself, 
and under its use dropsy often disappears in a few days. It 
should be given in fifteen-grain doses of the powder, in seltzer 
water, every four hours. Hale recommends codea phosphate 
(gr. y^ to y^) when morphine is not well borne ; it is, like mor- 
phia, given hypodermically. 

Dropsy occurs often and proves difficult of management. 
The remedies likely to be of value are the heart stimulants, 
led by Digitalis. Remedies whose action is centered upon the 
kidneys, stimulating the secretion of urine, are of no great ser- 
vice here.— Apocynum cannabinum and Stigmata maidis may 
prove useful, but must be given in physiological doses. Hy- 
dragogue cathartics are undoubtedly indicated, for they meet 
the rational indications : depletion of the blood and promotion 
of the absorption of the fluid. Of these, Elaterium is valuable 
on account of the promptness of its action. It may be given 
in light doses (lx or 2x of Elaterin) every three or four hours. 
Both citrate of caffeine and diuretin are highly useful; ex- 
cellent effects, in the experience of the dominant school, have 
followed the administration of calomel in 3-grain doses, three 
times daily. Milk diet is highly recommended. These means 
having failed, scarification under antiseptic precautions be- 
comes necessary to provoke the slow escape of large amounts 
of serum. 

Gastric Symptoms are usually the result of venous engorge- 
ment and catarrhal irritation. The nausea and vomiting often 
are persistent. Of the remedies symptomatically indicated I 
have had the best results from Arsenic, Ipecacuanha and 
Hydrocyanic acid. Kreosote, Hydrocyanic acid and Oxa- 
late of cerium are recommended by Osier. Bits of ice, milk- 
and-lime water, and iced champagne frequently are very sooth- 
ing, and they may be borne when the stomach will tolerate 
nothing else. 



1092 DISEASES OF THE ORGANS OF CIRCULATION. 

Sleeplessness adds to the suffering which arises toward the 
termination of valvular disease. Making all due allowance for 
the strongest arguments to be advanced against the use of 
hypnotics and narcotics, the stubborn fact remains that the 
finest-spun theories often melt into nothingness when brought 
face to face with experience in the sick room. In the present 
case all that can be done to remove the immediate cause of 
sleeplessness must be done patiently and perse veringly, and often 
much can be accomplished in that direction by the indicated 
remedy ; but if these measures prove insufficient, and the expe- 
dient of trjnng various arrangements of bedding to secure com- 
fortable position of the sick, with a hot toddy at night, or a 
dose of spirits of chloroform, have all failed, then recourse 
must be had to lrypnotics, preferably morphine. 

Diet. — Avoid all food which creates a tendency to flatulency, 
as fats and carbo-hydrates ; on the other hand, coarse foods 
which are likelj- to set up fermentation are also objectionable. 
Neither is it wise to encourage the use of "bulky" foods and of 
liquids in large amounts. White meats, beef-juice, scraped 
beef quickry broiled, fish, eggs and egg-albumen, and milk are 
excellent. If accustomed to the use of wine, the lighter wines 
may be taken moderately, especially in those of advanced 
years ; but alcohol, tea and coffee possess qualities which ren- 
der them dangerous to persons suffering from valvular disease, 
and if allowed at all, they must be taken very weak and with 
great caution. 

HYPERTROPHY OF THE HEART. 

The term "Hypertrophy of the heart" is used to describe an 
enlargement of the organ from thickening of its muscular 
walls. The Ivypertrophy is simple when there is no enlarge- 
ment of the cavities of the heart; eccentric, when the chambers 
of the heart are dilated ; concentric when the chambers of the 
heart are diminished in size ; the latter is probably a post- 
mortem change, due to rigidity and contraction after death. 

./Etiology. — Thickening of the heart-muscle is due to increased 
work of the organ and depends upon the maintenance of in- 
creased nutrition. The conditions demanding increased mus- 
cular effort on part of the heart are : Obstruction in the gen- 



HYPERTROPHY OF THE HEART. 1093 

eral arterial system (aortic hyperplasia, aneurism, arterio- 
sclerosis with or without renal disease). Obstruction in the 
pulmonary circulation (pulmonary cirrhosis and emphysema ; 
compression of the lungs, as from chronic pleurisy or curvature 
of the spine). Obstruction in the heart itself (valvular disease, 
pericardial adhesions, sclerotic myocarditis). Excessive ac- 
tion of the heart (athletic exercises). The specific action of cer- 
tain poisons (tobacco, alcohol, tea) and obesity, including the 
excessive use of beer. 

Osier's tabulation shows that general enlargement of the 
heart or of the left ventricle alone results from : disease of the 
aortic valve ; mitral insufficiency ; pericardial adhesions ; scle- 
rotic myocarditis ; disturbed innervation, with over-action of 
the heart ; general arterio-sclerosis ; increased arterial tension 
by contraction of the small arteries, necessitating greater exer- 
tion on part of the heart to force the blood through the gen- 
eral circulation ; prolonged muscular exertion ; increasing 
arterial blood-pressure ; narrowing of the aorta. Hyper- 
trophy of the left ventricle arises from : lesions of the mitral 
valve; pulmonary lesions with obliteration of pulmonary 
blood vessels ; sometimes valvular lesions on the right side ; 
chronic valvular lesions of the left heart; pericardial adhe- 
sions. 

Auricular hypertrophy is always attended with dilatation. 
The left auricle is hypertrophied and dilated in lesions of the 
mitral orifice ; the right auricle from increase of blood pressure 
in the lesser circulation (mitral stenosis, pulmonary lesions) 
or, more rarely, from narrowing of the tricuspid orifice. 

Morbid Anatomy. — The most striking feature is the increase 
in the weight and size of the heart. The former is especially 
significant. The average weight of the normal heart is from 
eight to nine ounces ; the hypertrophied heart may weigh from 
sixteen to twenty ounces, and cases are on record in which 
fifty- three, fifty-seven and sixty -four ounces were attained. 
The enlargement of one or the other of the chambers of the 
heart necessarily changes the shape of the organ ; usually the 
apex is much broadened. Great enlargement of the left ventri- 
cle gives to the heart an elongated, and extensive hypertrophy 
of the right ventricle a widened, appearance. Hypertrophy 
and dilatation of both ventricles results in the so-called cor 



1094- DISEASES OF THE ORGANS OF CIRCULATION. 

hovinum. The muscle is deep-red, firm, and cuts with much 
resistance ; the right ventricle especially, when hypertrophied, 
becomes leathen\ There is enlargement of the papillae and 
trabecular, and flattening of the papillary muscles when there 
is much dilatation. 

Symptoms. — During the state of simple hypertroplry few 
symptoms, perhaps not any, may be experienced ; this applies 
especially to persons whose nervous s^-stem is well balanced 
and who do not use tobacco or stimulants. A sense of weight 
and fulness in the chest, with some constriction about the 
heart, is often felt, associated with more or less dyspnoea and, 
in some cases, a clear consciousness of the cardiac impulse. 
Mam r of these symptoms become much exaggerated when 
lying on the left side, in bed, and then the patient can only sleep 
on the right side. While lying on the left side he feels the impulse 
of the heart ("thumping"), is conscious of fulness in the car- 
diac region, experiences an anno3'ing sensation as if the heart 
were beating in the ears, and grows nervous and apprehensive 
of danger. This state of nervous excitement in itself reacts 
upon the heart, and in many cases results in violent and pro- 
longed palpitation ; in others, change of position to the right 
side leads to a gradual disappearance of these symptoms, and 
the patient gently drops to sleep. There is not usually much 
pain at the heart, save in those who use tobacco excessively 
and in neurasthenics. There is sometimes much headache of a 
congestive type, with flushing of the face, throbbing of the 
vessels of the neck, noises and ringing in the ears, flashes of 
light before the eyes, and strong, full, resistant pulse. In such 
cases nasal, and even cerebral, haemorrhage may occur. Tend- 
ency to cerebral haemorrhage depends upon the continuously 
maintained high blood pressure which eventually leads to 
arterio-sclerosis. 

Physical Signs. — Inspection. There is bulging in the prae- 
cordial region, especially noticeable in children; widening of 
the intercostal spaces ; increase of the area of cardiac impulse 
downward and outward ; in marked cases the cardiac impulse 
is visible. — Palpation. The impulse is strong and heaving; 
slow and deliberate in simple rn-pertrophy, sudden and abrupt 
in eccentric hypertrophy. A second, weaker impulse is often 
felt at the apex or over the root of the aorta. The apex is dis- 



HYPERTROPHY OF THE HEART. 1095 

located downward and out-ward, as low as the sixth or eighth 
interspace. — Percussion. Increase of the area of dulness 
downward and out-ward, especially transversely (frequently 
transverse dulness of four inches, or more). — Auscultation. 
No abnormal sounds may be detected in the absence of valvu- 
lar lesions. Often the first sound is prolonged and dull (may 
be clear and sharp in eccentric hypertrophy), and there may be 
reduplication. In young people Laennec's metallic clink may 
accompany the first sound. The second sound is strong, often 
ringing or reduplicated in the aortic region. The pulse is 
strong, full, regular, with high tension ; if there is dilatation, 
it is full, but more rapid and with less tension, becoming inter- 
mittent and irregular as the heart fails. 

Hypertrophy of the right ventricle has bulging of the lower 
thorax, sometimes a tumor-like fulness in the epigastric region, 
with displacement, often of the apex beat to the left. Increase 
of cardiac dulness transversely and toward the right, some- 
times an inch beyond the sternal margin. The cardiac impulse 
is comparatively weak and diffuse. Auscultation reveals an 
abnormally loud first sound, which, in the eccentric form, is 
clear and sharp ; the second sound is accentuated and redupli- 
cated in the second left intercostal space. The pulse is usually 
soft and -weak. 

The physical signs of hypertrophy of the auricles are, as a 
rule, indistinct, since the condition is almost always associated 
with ventricular enlargement. 

Diagnosis. — The diagnosis depends upon the forcible, heav- 
ing heart impulse, the accentuation of the second sound at the 
base, and the increased area of dulness. The latter, however, 
is also found in pericardial effusion, aneurism, and in displace- 
ment of the heart forward against the chest wall. An ab- 
normally forcible beat of the heart, without hypertrophy, is" 
heard in cases where the heart is unusually exposed, as in case 
of imperfectly developed lung or of contraction or retraction of 
the lung by disease (cirrhosis, pleuritic adhesions, or phthisis). 
In either case the absence of the "heaving" character of the 
cardiac impulse and of the characteristic dislocation of the 
apex beat, with the positive evidence of pulmonary or other 
lesions, will determine the diagnosis. In nervous palpitation 
the impulse of the heart is often forcible, but never heaving. 



1096 DISEASES OF THE ORGANS OF CIRCULATION. 

Prognosis. — Hypertrophy of the heart once established, a 
cure is out of the question, save in cases where the hyper- 
trophy is moderate and depends upon transitory causes, as 
pregnancy, acute Bright's disease, the tobacco habit, etc. 
Such cases, however, are exceptional. The important point is 
to maintain perfect compensation, and to that end proper 
nourishment of the heart and avoidance of anything that 
throws upon it extra work must be made the object of special 
care. Conditions which render the prognosis unfavorable are 
anaemia and general debility, arterio-sclerosis and intercurrent 
acute febrile diseases, which in cardiac dropsy are frequently 
followed by myocarditis and degenerative changes of the heart 
muscle. Very severe muscular exertion and violent emotions 
often cause sudden breaking of compensation. 

For treatment consult the chapter on valvular diseases. 

DILATATION OF THE HEART. 

Dilatation of the heart in the great majority of cases depends 
upon the operation of two factors : increased pressure within 
the heart and impaired power of resistance. Increased pressure 
within the heart may be due to the existence of obstacles to 
the flow of blood or to the presence of an abnormally large 
amount of blood in the heart chamber ; in either case an ex- 
traordinary effort is necessary to meet the emergency, always 
involving the certainty of eventual exhaustion of nervous and 
muscular energy and probable degenerative changes in the heart 
muscle. Like other muscles, the heart by systematic training 
may be so developed as to become capable of enduring an 
unusual amount of exertion, as in athletes, whose success de- 
pends largely upon developing this faculty ; but if carried too 
far, "overtraining" brings dangers of its own. In persons of 
average capacity and health any special strain upon the heart 
is always dangerous ; the risk of permanent injury is greatly 
increased in those who are not rugged or who are poorly 
nourished. Impaired power of resistance is the immediate 
outcome of impaired nutrition of the heart-muscle, and in its 
milder forms is seen in anaemia, leukaemia and chlorosis. More 
often it is the effect of myocarditis or degenerative changes 
which occur in connection with certain acute infectious fevers, 



DILATATION OF THE HEART. 1097 

as typhoid and scarlet fever, and in endocarditis, pericarditis, 
especially with extensive adhesions, and in sclerosis of the 
coronary arteries. Aside from these, cases occasionally occur 
in which the affection appears idiopathic ; in some instances no 
cause can be assigned, while in others there is a history of a 
powerful emotion or of some violent physical effort, soon fol- 
lowed by dyspnoea, cough, pain and circulatory disturbances, 
either terminating fatally in a few days or becoming chronic. 
Another type has been described under the term "irritable 
heart;" it is usually seen in middle-aged men of good general 
health, engaged in occupations which require great physical 
efforts and who use stimulants freely ; it is common among the 
men employed in and about breweries, who habitually drink 
enormous amounts of beer daily. The symptoms here are 
those of cardiac irritability, with frequent spells of violent pal- 
pitation and dyspnoea, rarely much pain ; there are no charac- 
teristic post-mortem appearances. 

Morbid Anatomy. — Usually dilatation involves one or more 
chambers of the heart, and is associated with hypertrophy ; all 
the chambers of the heart may be greatly distended in aortic 
insufficiency. There may be thinning of the heart-wall; if so, 
there is increase in the size of the organ without increase of 
weight. The right side is affected oftener than the left, partly 
because of the frequency of pulmonary disease as an etiological 
factor. The conical outlines of the heart are usually lost, the 
organ appearing rounded. There is dilatation of the auriculo- 
ventricular rings, enlargement of the valvular orifices, and rela- 
tive valvular incompetency, with regurgitation. The orifices of 
the venae cavae and pulmonary veins may be greatly distended, 
the former especially so when there is tricuspid incompetency 
■with dilatation of the right auricle. The endocardium is 
usually opaque ; the muscle may be normal or reddish-gray 
or yellow in color, from parenchymatous or fatty changes. It 
is presumed that the ganglia of the heart undergo important 
degenerative changes, but as yet these are not understood. 
The affected chambers of the heart frequently contain large 
blood-clots which may extend into the vessels. 

Symptoms. — The symptoms of acute dilatation are: weak, 
rapid, irregular pulse; dyspnoea; obstructed venous circula- 
tion ; sometimes cardiac pain. Gradually developing dilatation 



1098 DISEASES OF THE ORGANS OF CIRCULATION. 

of the heart presents the general picture of valvular incompe- 
tency. The physical signs are such as suggest an enlarged, en- 
ervated organ, the various sounds produced being accompanied 
and obscured by the murmurs which arise from the incompe- 
tent state of the valves. The impulse of the heart is diffused, 
weak, wave-like, and frequently without a point of maximum 
intensity; Walshe has called attention to the fact that the 
latter may exist and be even visible, but cannot be felt. An 
area of cardiac dulness is observed when great hypertrophy is 
associated with dilatation. The sounds of the heart, with in- 
creasing dilatation, show less and less difference in distinctness, 
and the pause following the second sound is shortened, resem- 
bling the beat of the foetal heart (embryocardia); the galloping 
rhythm (bruit de galop), frequently heard, is especially charac- 
teristic of dilatation. The action of the heart is markedly ir- 
regular and intermittent, and any form of arhythmia may be 
present. The pulse is small, weak, and rapid. 

The diagnosis of dilatation is practically that of advanced 
valvular disease. 

The prognosis is serious, but cases which depend upon cura- 
ble causes may recover under appropriate treatment of the pri- 
mary disease. Acute dilatation may prove fatal within a few 
days. In chronic cases the outlook is discouraging and grows 
less hopeful as the dilatation increases. 

The treatment is that of valvular disease of the heart. 



DISEASES OF THE MYOCARDIUM. 

ATROPHY OF THE HEART. 

An abnormally small heart, small in size and weight, is al- 
most always the result of impaired nutrition, whether general 
or local. To the former belongs the cardiac atrophy of old age 
and of wasting disease (cancer, phthisis, diabetes, etc.); to the 
latter the limited forms of atrophy affecting only a portion of 
the heart, resulting from the pressure of a tumor, from peri- 
cardial effusion, or from obstruction to the coronary circula- 
tion. The condition may be congenital, due to aplasia (lack of 



ACUTE MYOCARDITIS. 1099 

development), in which case evidence of stunted growth is 
seen elsewhere, as in the smallness of the arteries and the im- 
perfect development of the genitalia (chlorotic young girls). 
It is also occasionally seen in men suffering from haemophilia. 
The reduction in the size and weight of the organ may be very 
great ; thus in the case of an adult under Bramwell's observa- 
tion the heart weighed less than three ounces. The heart loses 
its subpericardial fat, the surface appears shriveled and 
■wrinkled, the muscular tissue pale or dark-brown, ochre-like 
("brown atrophy"), the fibres present more or less evidence of 
granular or fatty degeneration, and the valves are thin and 
slender. 

Since in nearly every case the heart is able to meet the con- 
stantly lessening demands made upon it, no serious disturb- 
ances are produced. The physical signs are simply those which 
must result from the reduced size and the -weakness of the or- 
gan, as: diminished area of cardiac dulness ; weak and impal- 
pable apex beat; small and weak pulse. Abnormal heart 
sounds are rarely present. The affection is not easily recog- 
nized with any degree of certainty ; the prognosis and treat- 
ment are that of the general affection of -which the cardiac 
atrophy is a local expression. 

Enlargement (hypertrophy and dilatation) of the heart has 
been discussed in connection with valvular diseases. 



ACUTE MYOCARDITIS. 

Inflammation of the interstitial tissue of the heart-muscle is 
diffuse or localized. Diffuse myocarditis oftenest occurs in con- 
nection with acute infectious fevers, as typhoid fever, diphthe- 
ria and scarlet fever, and -with septic processes. It is also, but 
more rarely, a result of an existing pericarditis or endocarditis. 
It usually affects the left ventricle and involves more or less 
extensive areas. In some cases the inflammation is confined to 
the papillary muscles, in others to the muscular rings sur- 
rounding the valvular orifices (mitral and tricuspid). It ter- 
minates in resolution, chronic fibroid myocarditis, rarely in en- 
docarditis or pericarditis, very exceptionally in suppuration. 
The characteristic anatomical changes consist of softening of 
the heart-muscle, which at first is of a dark-red color with 



1100 DISEASES OF THE ORGANS OF CIRCULATION. 

points and dots of hemorrhagic injection; later the appearance 
is yellowish-red and mottled, and finally 3 r ellowish-gra3\ Mi- 
croscopically there is granular or fatty degeneration of the 
muscular fibre, sometimes hyaline transformation. A trans- 
verse division or "segmentation" of the fibres is frequently 
seen post-mortem. A localized or suppurative myocarditis also 
occurs in connection with acute infectious diseases, but is much 
oftener the result of infection with the micro-organisms of sup- 
puration carried to the heart from suppurative disease of the 
endocardium or pericardium, or as emboli in the branches of 
the coronary arteries in puerperal septicaemia, suppurative 
phlebitis, etc. The heart-muscle, upon section, is seen to be 
covered with numerous grayish-white spots or streaks, some- 
times as large as a kernel of wheat, consisting of a mass 
of micrococci surrounded by leucocytes ; each of these re- 
sults in a small abscess, with degeneration or destruction of 
the adjacent muscular fibres. These abscesses may be quite 
numerous ; they are oftenest seen on the anterior wall of the 
left ventricle, near the apex. Incidentally there may occur 
rupture of the abscess into the pericardial sac, giving rise to 
suppurative pericarditis, or rupture into the cavity of the 
heart, causing malignant endocarditis and general septicaemia; 
or if the septum is the seat of suppurative processes, extensive 
perforation of the septum may occur ; or there may be aneuris- 
mal dilatation at the seat of the abscess, resulting in rupture 
of the heart or, if within the septum ventriculorum, a rupture 
into either ventricle. The termination is almost surely fatal. 
Exceptionally encapsulation may take place, with inspissation 
of the contents and the formation of calcareous bodies. 

The symptoms of the cardiac lesion are vague, for they are 
largely covered by those of the primary disease. More or less 
dyspnoea, some pain, cough and a sense of weakness of the 
heart are usually present. The action of the heart is rapid, 
with paroxysms of great acceleration of the heart-beat, some- 
times as high as two hundred to the minute. In diseases liable 
to give rise to myocarditis, the sudden appearance of arlry- 
thmia, or of an aggravation of the fever, possibly assuming a 
septic type, indicate the accession of this complication. Sudden 
dilatation of the heart or embolisms are recognized without 



ACUTE MYOCARDITIS. 1101 

much difficulty from the character of the symptoms to which 
they give rise. 

The physical signs are those of weak heart, dilatation, or 
valvular involvement. 

The diagnosis is uncertain, and the prognosis grave in all but 
light cases of the diffuse form. Death may result with start- 
ling suddenness in the infectious fevers, especially in diphtheria ; 
on the other hand, recovery may take place even in the sup- 
purative form, as demonstrated by the occasional presence, 
post-mortem, of encapsulated calcareous masses in the sub- 
stance of the heart muscle. 

Treatment. — The most important item is absolute rest, 
which must be maintained throughout and is not to be broken 
under any circumstances, since even a very moderate effort on 
part of the patient may be followed by fatal collapse. It is on 
this account that all the wants of the patient, including feed- 
ing and attention to the calls of nature, must either be met 
while he is in the recumbent position or in such a manner that 
it precludes the slightest exertion on his part; he must not 
even be allowed to turn from one side to the other without 
assistance. The diet must be nourishing and easily digested. 
Milk answers every purpose, and is best taken diluted with 
Vichy water. If a more generous diet is demanded, fish, the 
white meat of fowl, or a very tender, carefully broiled small 
piece of steak may be added. Fruit, ripe and taken in mod- 
erate amounts, is unobjectionable. If there is much precordial 
distress, cold applications may prove a source of relief. Alco- 
holic stimulants, if given at all, must be used with great care. 

Therapeutics. — Of remedies, those capable of exerting a bene- 
ficial effect in pericardial and endocardial inflammation are 
indicated, and these chapters must be consulted. Aconite and 
Veratrum, -when exhibited, must not be used in the lower 
attenuations or mother tincture, lest they aggravate the con- 
dition they are expected to relieve. "Heart-tonics," especially 
Digitalis, must be avoided ; they increase the danger of rup- 
ture of the heart in case of suppuration ; if prescribed at all, 
they must be administered in minute doses. Arsenicum, Phos- 
phorus, Lachesis, Crotalus, and other remedies of this class, 
must be carefully studied in serious cases. The heart-symp- 
toms alone will rarely furnish the key to the remedy ; it lies in 
the totality of symptoms. 



1102 DISEASES OF THE ORGANS OF CIRCULATION. 

CHRONIC MYOCARDITIS. 

Chronic myocarditis or ' ' fibroid ' ' heart is an inflammatory 
affection of the interstitial connective tissue of the heart, asso- 
ciated with hyperplasia, and leading to induration of its sub- 
stance. 

^Etiology. — The most prolific cause of fibrous heart is disease 
of the coronary arteries, resulting in insufficiency of the blood 
supply to the heart, giving rise to anaemic necrosis or, in case 
of extensive stoppage of the circulation, as by obliteration 
of one of the coronary arteries, to the formation of large 
areas of sclerosis. The element of disturbed nutrition of the 
heart is an important one, and is chiefly responsible for the 
occurrence of chronic myocarditis in many cases of valvular 
disease. Sometimes the affection follows diffuse acute myelitis, 
especially when this disease depends upon acute articular 
rheumatism ; exceptionally it arises from infection by the bacil- 
lus tuberculosis or the virus of syphilis. The preponderance of 
coronary disease in men past middle age and the general tend- 
ency of advanced years to sclerotic changes accounts for the 
more frequent occurrence of the affection in men at that period 
of life. 

Morbid Anatomy. — The essential feature consists of over- 
growth of interfibrillar connective tissue, with development of 
fibrous tissue, which encroaches upon the muscular structure, 
leading to atrophy and degeneration of the latter; in some 
cases the atrophy of the muscular fibres is extreme. These 
changes may be limited to a small area, as when due to 
anaemic sclerosis depending upon general innutrition of the 
heart from general disease. They are oftenest seen in the left 
ventricle, papillary muscles, and septum of the heart. The 
heart itself is increased in size and weight ; dilatation occurs in 
advanced cases, and is most marked when there is adherent 
pericardium. The heart wall is firm and resistant to the knife, 
in places almost cartilaginous. Thickening of the endocardium 
is frequent. The coronary arteries present sclerotic changes 
and the terminal branches are narrowed, sometimes occluded. 
Obliterative endocarditis occurs oftenest in syphilitic subjects. 
With increasing weakness of the heart distant organs undergo 
changes such as are found in advanced valvular disease. 



CHRONIC MYOCARDITIS. 1103 

Aneurism of the heart results from localized sclerosis ; saccular 
dilatation may take place from the giving way of the inelastic 
fibrous tissue before the intracardial pressure. 

Symptoms. — The beneficent effect of compensatory hyper- 
trophy is responsible for the frequency with which during life 
appreciable disturbances of health are "wholly wanting and the 
existence of serious heart trouble is not even suspected. When 
symptoms appear, they are simply those of a failing heart and 
present nothing diagnostic of the type of the affection. There 
is palpitation and irregular action of the heart, more or less 
dyspnoea from exertion, and constriction and uneasiness at the 
heart. Exceptionally paroxysms of angina pectoris occur. 
The pulse is usually decreased in frequency ; it may be regular, 
but is more likely to be intermittent and unequal. In more 
advanced cases there may be profound syncope from any 
mental excitement or physical exertion, even resembling apo- 
plectic seizures. As dilatation takes place, the symptoms as- 
sume the character peculiar to that condition. Cerebral anae- 
mia is pronounced in many cases. 

The physical signs are indefinite. 

The diagnosis under these circumstances cannot often be pos- 
itive. It depends upon the existence of a demonstrable cause 
and of progressive cardiac weakness, dilatation, cerebral anae- 
mia, abnormality of the pulse, ready loss of the heart's balance 
from any sudden exertion, confusion of ideas and syncope. The 
cases which are easiest recognized are those generally known 
as "senile heart." 

The prognosis is decidedly unfavorable so far as recovery is 
concerned, but hopeful as to duration of life, provided due care 
is exercised not to tax the heart severely, especially by violent 
physical exertion. Sudden death may occur from syncope or 
angina pectoris. 

Treatment. — Generally speaking the treatment is that of 
hypertrophy and dilatation, with particular reference to the 
first cause. While the patient is still able to be about, every 
means within reach should be utilized to invigorate the heart, 
and to this end nothing is more effective than a quiet life in the 
open air, with enough exercise to act as a mild tonic without 
producing excessive weariness, dyspnoea or cardiac pain. The 
value of this measure cannot be overestimated, and if the 



1104 DISEASES OF THE ORGANS OF CIRCULATION. 

patient's means allow it, he may indefinitely prolong life and 
reasonably good health by living where these advantages can 
be enjoyed. It is evident that a low altitude, even the sea- 
level, is a necessity ; but lovers of mountain scenery may con- 
sole themselves in the knowledge that under favorable condi- 
tions the heart may be toned up sufficiently to endure quite 
an elevation, provided good judgment is exercised in daily 
habits and employment. The sea-coast of Southern California, 
with its freedom from great heat in the summer and severe 
cold in the winter, offers unequalled inducements to such cases. 
As to daily life, freedom from excitement, abstinence from 
coffee, tea, alcoholic stimulants and tobacco, with regular and 
moderate exercise are necessary ; a rapid cold bath, followed by 
brisk rubbing, may be taken every second day. Cardiac stimu- 
lants may be required ; of these strychnia is here especially 
valuable. The precautions necessary in the use of digitalis 
were pointed out elsewhere (see Valvular Diseases). Stroph- 
antus and sparteine frequently are useful; the latter may 
be given hypodermically, in doses of Vs to M of a grain several 
times daily. Nitro-glycerine, amyl nitrite, and other drugs 
of use in valvular disease, are emploj^ed as indicated. In case 
of syncope the clothing about the neck must be loosened, the 
head lowered, ammonia beheld under the nose, and hot whiskey 
given internally. Threatening collapse is met by subcutaneous 
injections of camphor (camphor one part; ether ten parts, a 
syringe full every fifteen or twenty minutes; Whittaker) or 
sodium benzoate in five-grain doses by the mouth or three- 
grain doses hypodermically. 

DEGENERATIONS OF THE MYOCARDIUM. 

Parenchymatous Degeneration. — This disease, formerry con- 
sidered a parenchymatous myocarditis, consists of a degenera- 
tion of the muscular fibres, which are more or less densely in- 
filtrated with granules that resist the action of ether, but are 
soluble in acetic acid and dilute solutions of caustic potash. 
The myocardium becomes pale, turbid, and soft. The affection 
is oftener seen in the left heart, but may affect any part of the 
organ. It occurs usually in fevers (especially diphtheria, ty- 
phoid fever, scarlet fever), but no definite relation seems to 



DEGENERATIONS OF THE MYOCARDIUM. 1105 

exist between it and the high temperature characterizing them. 
The symptoms are those of diffuse myelitis. 

Fatty Heart. — Two forms are recognized: (a) fatty infiltra- 
tion or overgrowth and (b) fatty degeneration. 

(a) Fatty Overgrowth (cor adiposum) is found more than 
twice as often in men as in women, and fully eighty per cent, 
of the cases occur between forty and seventy years of age. The 
condition consists of an excess of sub-pericardial fat, envelop- 
ing the entire heart in a layer of fat which may reach the thick- 
ness of one-half inch, or in an infiltration of fat into the muscu- 
lar fibre, separating the muscular strands, penetrating even as 
deep as the endocardium, especially in the right ventricle, and 
impairing the contractile power of the heart. The muscular 
fibres become atrophied (simple or brown atrophy), or are filled 
with albuminous granules or drops of oil, or show traces of 
fatty degeneration. There is usually relaxation of the heart 
and dilatation of the chambers. The symptoms are those of 
cardiac weakness, with a pulse which usually, but not always, 
is rapid and weak. Fatty infiltration may result in rupture of 
the heart. 

(b) Fatty Degeneration. — Fatty degeneration of the heart is 
in reality a part process of myocarditis. It is oftenest seen in 
men of advanced years, and very largely depends upon failing 
nutrition. The immense amount of work done by the heart 
muscle requires perfect nutrition; interference with its nutri- 
tion is followed by serious results ; hence the proneness of the 
heart to degeneration, which is especially marked in those 
parts of the heart muscle which do the larger amount of work. 
The aetiology then embraces constitutional states marked by 
loss of vitality and impaired nutrition, as : old age, profound 
anaemia, wasting diseases, cachexia, great loss of blood, acute 
infectious diseases, and poisoning by phosphorus, arsenic, and 
alcohol ; it also includes certain local diseases, especially peri- 
carditis, coronary disease and, to a limited extent, ventricular 
hypertrophy in valvular affections. 

Morbid Anatomy. — The heart is large, flabby, tears easily, 
and is of yellow-brown color. The fatty degeneration usually 
occurs in masses and becomes diffuse by dissemination and 
coalescence, with spots of the most intense degeneration; stria- 
tion does not essentially suffer; segmentation occurs often. 
70 



1106 DISEASES OF THE ORGANS OF CIRCULATION. 

Fatty degeneration seldom stands in direct relation to the dila- 
tation and hypertrophy of individual sections of the heart, for 
when one chamber only is hypertrophied both sides may show 
fatty degeneration ; when resulting from toxic action, the fatty 
degeneration is rarely uniform, but is especially marked in cer- 
tain circumscribed areas ; the laj^ers under the epi- and endo- 
cardium show the most pronounced fatty degeneration 
(Gcebel). The microscope proves that in the early stage rows 
of minute globules are arranged along the line of the primitive 
fibres ; in the advanced stage the fibres are completely occupied 
by them. 

Symptoms. — Fatt}^ degeneration often is latent. When there 
is disturbance of health, the symptoms are those of weak, fail- 
ing heart. Very often the heart does its work with perfect reg- 
ularity in spite of extensive degeneration ; in fact, it is only 
when dilatation has begun that the condition arouses atten- 
tion. Dyspnoea, pain at the heart, often paroxysms of angina 
pectoris, "bad spells," with asthma from exertion or over- 
eating, attacks of syncope, slow pulse and similar disturb- 
ances show themselves. There is much mental and physical de- 
pression. The skin is often pallid, almost waxy, especially 
under the eyes and about the nose ; there may be a segment of 
discoloration in the upper zone of the cornea (arcus senilis), 
but this is no longer considered characteristic. Sometimes 
there is great emaciation. Mental symptoms may be pro- 
nounced, the patient suffering from delusions or even mania. 
Che^me-Stokes breathing is frequently seen in the late stage. 
Congestion of inner organs and oedema are not so frequent or 
marked as in valvular disease. 

The physical signs are indistinct, and the diagnosis is practi- 
cally limited to the recognition of heart failure, with mere in- 
ference as to its specific cause. 

The prognosis depends upon the extent and rapidity of the 
degenerative changes, and, in the main, is decidedly unfavora- 
ble. 

The treatment in well established cases consists of absolute 
bodily and mental rest and of a diet which is nourishing and 
easily assimilated, and from which sugar and starch are rigidly 
excluded. The dietetic rules practiced in the treatment of 
obesity must be observed. Overeating is to be scrupulously 



ANEURISM OF THE HEART. 1107 

avoided. Heart stimulants must be used with caution, espe- 
cially digitalis in any but very light doses, and all the rules 
applicable to the treatment of cardiac dilatation are to be 
observed. In case of sudden heart failure the diffusible stimu- ' 
lants (ether, ammonia, alcohol) are indicated; amyl nitrite 
and nitro-glycerine may be demanded (arterio-sclerosis). Par- 
oxysms of severe pain at the heart or angina are to be met 
with hot applications over the heart, alcoholic stimulants in 
hot water or milk, nitro-glycerine or amyl nitrite; morphia 
must not be used save as it is unavoidable, and then with great 
care. 

Other forms of degeneration of the heart are: amyloid degen- 
eration, hyaline transformation of Zenker, and calcareous de- 
generation. They are infrequent and of slight practical im- 
portance. — Osier in substance gives the following excellent 
summary of myocardial disease: (1) Cases in which sudden 
death occurs with or without previous indications of heart- 
trouble. These cover sclerosis of the coronary arteries, exten- 
sive fibroid disease, and fatty degeneration. Many patients 
never complain of cardiac distress, but enjoy unusual vigor of 
mind and body. (2) Cases in which there are cardiac arrhyth- 
mia, shortness of breath on exertion, attacks of cardial 
asthma, sometimes of angina, symptoms of collapse, with 
sweats and extremely slow pulse, and occasionally marked 
mental symptoms. In these cases the condition may be 
strongly suspected and, in some instances, diagnosed. A dis- 
tinction between the fatty and fibroid heart is rarely possible. 
(3) Cases in which there are cardiac insufficiency and symp- 
toms of dilatation. Dropsy is often present, and with a loud 
murmur at the apex it may be difficult, unless the case has 
been seen from the outset, to determine whether or not a 
valvular lesion is present. 

ANEURISM OF THE HEART. 

Aneurism of the wall of the heart is a rare condition, always 
the result of weakness of the tissue texture of the heart which 
eventually renders it unable to resist the pressure of the blood 
within. The outward pressure of the blood forces the formation 
of a depression on the inner surface of the heart at the point 



1108 DISEASES OF THE ORGANS OF CIRCULATION. 

of greatest weakness, and finally creates a sac or pouch which 
communicates with the heart freely or by a constricted open- 
ing. Aneurism is acute or chronic, according to the nature of 
' the disease which is responsible for the textural change causing 
the aneurism. Such changes occur in inflammatory conditions 
of the substance of the heart and of the endocardium, in fibrous 
changes of the heart, in fatty degeneration, and in the soften- 
ing of the heart accompanying syphilitic and tuberculous dis- 
ease. The condition is most frequently seen at the left ventri- 
cle, near the apex, and appears to occur oftener in men than in 
women. The size of the tumor varies ; it may rival the heart 
itself. The contents of the sac are usually blood clots or layers 
of fibrin, of which the outer layers may be organized and ad- 
herent to the heart-wall. 

The symptoms are vague, merely indicative of disease of the 
heart. 

Of physical signs, a bulging in the region of the apex may be 
visible if the aneurism is very large, or there may be a marked 
disproportion between the strong impulse of the heart and the 
feeble pulsation in the peripheral arteries. The duration of life 
under such circumstances is wholly problematical, and depends 
altogether upon the condition of the heart which gave rise to 
the occurrence of this accident. 

Treatment is limited to alleviating measures. 

Aneurism may occur in a valve, from similar causes, usually 
an acute endocarditis. The mechanism is the same as in aneur- 
ism of the wall. The entire thickness of the valve may be 
dilated and form a pouch, or a sac may be formed by destruc- 
tion of one of the lamellae. Valvular aneurisms rupture soon 
and cause perforation and insufficiency of the affected valve. 

RUPTURE OF THE HEART. 

Rupture of the heart occurs in diseases of the heart muscle, 
especially'- in fatty degeneration, more readily when localized ; 
also in acute softening which results from embolism of a 
branch of the coronary artery, from suppurative endocarditis, 
and from syphilitic gummata. The immediate cause is oftenest 
a strain. Rupture generalh^ occurs in the left ventricle (anterior 
wall), rarely in the right ventricle, still more rarely in the 



TUMORS OF THE HEART. 1109 

auricles. The tear is usually parallel with the septum; the 
blood is emptied into the pericardial, sometimes into the 
pleural, cavity. 

The symptoms are : sudden onset of intense, agonizing pain 
in the region of the heart, with sense of overwhelming suffoca- 
tion, loss of consciousness, and death. Quain states that sud- 
den death occurred in 71 per cent, of his cases. If death does 
not occur for several hours, the intense anguish may grow less 
and the patient may recover consciousness ; but there is pro- 
found collapse, with great dyspnoea, cold sweat, coldness of 
the body, nausea and vomiting, fainting; the action of the 
heart is usually bounding and tumultuous. If the rupture is 
partial, the patient may live for several days. Death occurs 
from shock and sudden paralysis. 

The diagnosis is very difficult, and the prognosis hopeless. 

Treatment is limited to the application of cold (ice bags) 
over the heart, the enforcing of complete rest, and the relief of 
pain by such measures as suggest themselves. Sinapisms to 
the extremities are recommended for the purpose of drawing 
the blood from the heart, but they are of slight value. Diffus- 
ible stimulants may be required to mitigate the effects of the 
shock. Rupture of the heart from wounds belongs exclusively 
to the domain of Surgery. 

TUMORS OF THE HEART. 

Tumors of the heart are rare. Carcinoma is almost always 
secondary. It may involve any part of the heart and multiple 
deposits of a cancerous character may be found throughout 
the heart substance. It usually results from extension by con- 
tiguity or continuity of structure. Sarcoma is even more rare ; 
it is usually seen in the young, and is characterized by rapidity 
of growth. The left side of the heart is generally affected. 
Myxoma have been found in nine cases, and always in the left 
auricle, ''forming nodular tumors of transparent gelatinous 
consistence, attached by a thin pedicle to the wall." In all the 
cases the patients had suffered from apoplectiform attacks. 
The existence of fibroma has been reported by several observ- 
ers. In one case there was infarction of the spleen and kidneys; 
in another, involving the substance of the heart wall, the 



1110 DISEASES OF THE ORGANS OF CIRCULATION. 

symptoms were remarkable smallness of the pulse and par- 
alytic seizure ; in a case of fibrinous cyst in the left auricle there 
was rupture, apoplexy, typhoid symptoms, and death. Cysts 
in the heart are rare ; they are filled with a clear or brownish 
fluid, sometimes with blood. 



NEUROSES OF THE HEART. 

PALPITATION. 

"Palpitation of the heart may be defined as a beating of the 
heart which is felt and which disturbs the patient. Whatever 
the cause, all palpitations have the common character that the 
patient feels his heart beat." (Laennec.) A physiological in- 
crease in the rapidity or force of the heart beat, as from an 
exertion, is not palpitation ; the subjective sensation that the 
heart's action is disturbed is the essential feature. 

/Etiology. — Palpitation, as here considered, is essentially an 
expression of disturbance or increased excitability of the ner- 
vous system ; it is, therefore, frequently found in connection 
with hysteria or neurasthenia, and under conditions and at 
periods of life when such states are most liable to occur. Peo- 
ple of sedentary life and luxurious habits, who practice all 
sorts of self-indulgence, furnish a large per cent, of neurotics 
and of palpitation ; the laboring man whose life is spent in 
hard toil and whose habits are regular is practically exempt. 
Whenever hysteria and neurasthenia are characterized by some 
form of indigestion, palpitation is almost sure to be an annoy- 
ing element of the case. Women are particularh- subject to it 
at puberty, at the climacteric period, and frequently during 
menstruation. Emotions, especially fright, are exciting causes, 
and in persons subject to palpitation so trifling a matter as the 
unexpected entrance of a stranger, or even of an acquaintance, 
or the necessity of submitting to an examination of the heart, 
possibly for life insurance, may bring on a violent attack of 
palpitation ; stage-fright often assumes this form. The ease 
with which in proper subjects the heart may be completely 
upset is astonishing. I know of a case in which the conscious- 



TACHYCARDIA — RAPID. HEART. 1111 

ness of being closely observed is in itself quite sufficient to cause 
distressing palpitation. Other factors are: tea, coffee, tobacco, 
alcohol, indigestion. Palpitation also occurs during and after 
recovery from exhausting illness, as from acute fevers, in con- 
nection with various affections of the heart, especially myocar- 
dial and valvular disease, and not infrequently, in my experi- 
ence, as an aura in epilepsy. I have under observation a pa- 
tient in whom a violent attack of palpitation has taken 
the place of an epileptic seizure. 

Symptoms. — Palpitation occurs in paroxysms of subjectively 
recognized tumultuous action of the heart, often excited by 
trifling causes or even a mere apprehension. Patients com- 
plain of a variety of sensations referable to the heart, a chok- 
ing sensation or distressing fulness at the heart, a sensation as 
if the heart were jumping into the throat, as though it were 
rolling over, as though it were "unhinged," as though it 
would stop beating. There is always associated with it a 
sense of great danger, which cannot be overcome by the pa- 
tient's positive knowledge that such danger does not exist. 
Hence, the countenance may be cold, the forehead covered with 
sweat, and the expression of the face one of great apprehension 
and profound alarm. Often there are visible pulsations against 
the chest wall, much dyspnoea, and a rapid, full pulse, some- 
times reaching 1 50 beats in the minute. The attack may cease 
abruptly; oftener it disappears gradually; usually it leaves 
the patient much exhausted. The duration varies from a few 
minutes to an hour, or more. Copious emissions of pale, 
limpid urine after the attack has ceased are common, especially 
in hysterical subjects. Recurrences after a brief interval are not 
infrequent, and several days may pass before the heart resumes 
a state of normal tranquility. It is said that in some patients 
threatening attacks may be aborted by a severe physical exer- 
tion. The physical signs are vague ; if arising from organic 
disease of the heart, the signs belonging to such a state are, of 
course, present. The prognosis is good, save in the presence of 
organic cardiac disease. 

TACHYCARDIA— RAPID HEART. 

Making due allowance for the fact that in some persons the 
action of the heart is remarkably rapid through life, and that 



1112 DISEASES OF THE ORGANS OF CIRCULATION. 

often a sudden rise in the heart's rapidity is to all intents and 
purposes purely a physiological process, there are other cases of 
rapid heart which are undoubtedly pathological. These often ap- 
pear closely related to palpitation, both as to causation, symp- 
tomatology and treatment ; but differentiation is easy when it 
is remembered that in palpitation the subjective sensation of 
cardiac disturbance is the essential feature. The exhaustive 
arrangement of the causes of taclvycardia made by Larcena is 
about as follows: (1) Diseases of the heart and blood-vessels 
(overstrain, hypertrophy of growth, myocarditis, acute endo- 
carditis, valvular disease, pericarditis, angina pectoris, aortitis, 
arterio-sclerosis, cardiac affections from Bright's disease). (2) 
Febrile conditions. (3) Compression of the vagus, either trunk 
or nucleus. (4) Organic disease of the nervous system (bulbar 
disease, softening in the medulla, medullary affections, acute 
ascending paralysis, acute myelitis, progressive muscular 
disseminated sclerosis, multiple sclerosis of the pyramids with- 
out lesion of the anterior horns, tabes dorsalis, syringo-myelia, 
degeneration of the vagus in tabes dorsalis, polyneuritis, 
beri-beri). (5) General diseases, as typhoid fever, diphtheria, 
tuberculosis, carcinoma, chlorosis, syphilis, chronic malaria, 
chronic articular rheumatism, including convalescence and ex- 
haustion from disease. (6) Toxic action of alcohol, coffee, tea 
and drugs (digitalis, atropine). (7) Reflex from disease of the 
heart, brain, lungs, stomach, liver, intestine, abdomen, uterus, 
bladder, prostate gland, brachial plexus. (8) Neuroses: Graves' 
disease, hysteria, epilepsy and neurasthenia. 

Paroxysmal tachycardia appears to be of purely neurotic 
origin, the patient evidently enjo3 r ing good health, save sud- 
denly appearing paroxysms of increased action of the heart, the 
pulse reaching 200, or more. The immediate cause is in doubt. 
H. C. Wood thinks that the trouble lies in the centres of the 
accelerator nerves. Osier quotes Franck, who has shown that 
the acceleration of the heart's action is due to shortening of 
the diastole, and that during the systole the amount of blood 
expelled is so small that there is actually no increase in the 
amount of blood expelled in the minute. During the attack 
there may be felt some dizziness, and often, as in palpitation, a 
feeling of apprehension. The radial pulse is almost threadlike, 
and the heart impulse to the hand or ear scarcely perceptible, 



TACHYCARDIA— RAPID HEART. 1113 

resembling more a "vibratory" effort than a series of distinct 
beats. The first and second sounds are equal and there is no 
pause, the heart-beat resembling the ticking of a watch and 
the foetal heart-beat. The attack usually lasts for a few 
minutes, sometimes for a half hour, or more. There may be 
frequent recurrences for several days, and in such cases the 
rapidity of the heart may be increased to 200 and 300 (Whit- 
taker). 

The diagnosis is easy; the regularity of the heart -beat is im- 
portant in differentiating it from the rapid heart of cardiac dil- 
atation. 

The prognosis is good, so far as recovery from the individual 
paroxysm is concerned ; it is, however, evident that frequent 
recurrence of such intense activity must eventually destroy the 
heart. When associated with organic brain disease, the prog- 
nosis is necessarily serious. 

Treatment of Palpitation and Tachycardia. — It is of the 
greatest importance to ascertain the cause and then remove it, 
if possible. Conditions of nervous irritability from weakness 
may often be wholly eradicated, and with it the tendency to 
palpitation ; the same applies to indigestion. Each and every 
measure tending toward the establishment of good general 
health must be utilized, including a normal life, regular habits, 
regulated exercise, steady and agreeable employment, an abun- 
dance of sleep, etc., always with especial reference to the re- 
quirements of each case. Tobacco, coffee, alcoholic stimulants 
and any other agents which unfavorably affect the nervous 
system and the heart are to be prohibited. Attention to the 
details of the patient's diet, as the exclusion of starchy foods, 
is often followed by gratifying results. During an attack of 
palpitation the patient must be placed in a semi-recumbent po- 
sition, the clothing about the throat and chest loosened, and 
an abundance of fresh air admitted. If the action of the heart 
is very tumultuous, ice-bags or cloths wrung out of ice water, 
applied over the heart, often prove very beneficial. If there is 
pain at the heart, mustard draughts may afford relief. Aro- 
matic spirits of ammonia, in doses of 20 or 30 drops, or cam- 
phor in full doses, or a tablespoonful of brandy in hot water, 
may be beneficial. Usually the exhibition of the indicated 
remedy controls the attack in a reasonable length of time, and 



1114 DISEASES OF THE ORGANS OF CIRCULATION. 

• tends strongly to prevent its recurrence. Heart tonics, espe- 
cially strychnia, are of service after the attack has passed. 
Galvanism, applied daily, not more than five minutes, and of 
moderate strength, has yielded excellent results ; the positive 
pole is applied to the vagus at the inner surface of the sterno- 
mastoid, with the negative pole at the lower border of the 
sternum. 

The same general directions apply with equal force to the 
treatment of "rapid heart." The paroxysms, however, are 
much more difficult to manage. Ice-bags or cold compresses 
over the heart, Amyl nitrite, sometimes Nitroglycerine or 
Digitalis, the latter in organic disease, are indicated, but only 
too often prove of slight service. Nothnagel, Rosenfeld, and 
others, advise compression or irritation of the vagus. Rosen- 
feld, in the report of a case, describes the details of the treat- 
ment as follows : The patient, a lady, laid herself horizontally 
in bed, raised the head a little, and pushed the feet against the 
bed. She then made a deep inspiration and pressed the lungs 
down with all her power by forcible closure of the glottis. The 
diaphragm was likewise fixed by energetic action of the ab- 
dominal walls ; the arms were bent at the elbow and pressed 
upon the chest and sides of the thorax, while contraction of 
the pectoral muscles drew the chest backward. Thus the con- 
tents of the thorax were fixed in every direction, from above, 
from below, and from the sides, for fifteen or twenty, or more, 
seconds. The immediate effect of this pressure was an increase 
in the pause of the heart, a momentary standstill, followed by 
two or three strong and slow pulsations, and the attack was 
ended. During pressure the face becomes bluish, the eyes are 
prominent, the lips and nose are cyanotic. But as soon as the 
pulse becomes normal, the usual color of the face returns. 
(Whittaker in Twentieth Century Practice.) H. C. Wood 
relates a remarkable case of paroxysmal tachycardia in which 
the attack could always be aborted by drinking a glassful of 
very cold ice-water. 

Therapeutics. — If from hysteria : Ambra grisea, Asa fcetida, 
Camphora, Crocus, Ignatia, Nux moschata, Pulsatilla, 
Scutellaria, Sumbul, Valeriana. From mental excitement : 
Aconite, Camphor brom., Nitric acid, Nux vom., Opium, 
Scutellaria, Valeriana. From fright: Aconite. From ex- 



TACHYCARDIA— RAPID HEART. 1115 

cessivejor: Coffea. Fromgrief: Ignatia, Pulsatilla. From 
anaemia: Calc. carb., China, Cuprum, Ferrum, Helonias, 
Ignatia, Natrum muriat. From excessive physical exercise: 
Aconite, Coca. Sensation of trembling about the heart : 
Camphor, Digitalis, Kalmia, Lilium tigr., Natrum mur., 
Spigelia, Sumbul. 

Aconite. After fright or violent physical exercise ; in young 
and full-blooded persons ; with great oppression at the heart 
and tendency to syncope ; worse from every motion ; full, hard 
pulse ; fear of death. — Ambra grisea. In anaemic, exhausted, 
overworked, nervous subjects, suffering from nervous irrita- 
bility and insomnia, with pressure and uneasiness in the chest ; 
he worries about the heart, fancies he feels it beat all through 
the body. Not so useful in violent attacks of palpitation as 
in the constant fretting about heart-trouble in pale, exhausted, 
nervous subjects. — Asa fcetida. In hysterical women who are 
very sensitive to external impressions and who are subject to 
flatulency. The heart appears unhinged, flutters, beats rapidly, 
irregularly and feebly ; everything unexpected, no matter how 
trifling, upsets the heart. Flushing of the face; anxiety and 
restlessness, rather vague, but tormenting. At times intense 
and even painful pressure about the heart, evidently from gas- 
tric flatulency and relieved from the eructations of gas. — Amyl 
nitrite. Tumultuous action of the heart, with precordial 
anxiety, great oppression, sense of constriction about the 
heart, extending into the throat ; fluttering of the heart from 
slightest motion. — Aurum. Hypertrophy ; fatty heart ; palpi- 
tation brought on from even slight exertion, especially going 
up a hill ; feels as though the heart-beat were excessively pow- 
erful and would burst the chest from the pressure within. 
Must be active at some employment, cannot keep still. Sexual 
irregularity. Great mental depression ; worries constantly 
and threatens to commit suicide. Especially adapted to young 
people of scrofulous diathesis, suffering from the results of sex- 
ual vices, as excessive masturbation. — Belladonna. Chiefly 
indicated by actual congestion, rush of blood, great pressure 
about the heart, with anxiety and distress, headache, etc. 
Useful in some cases of palpitation in young women when, 
with this congested state, there is an explosive violent restless- 
ness, as though she would actually fly to pieces; she is vio- 



1116 DISEASES OF THE ORGANS OF CIRCULATION. 

lently hysterical, her eyes flash, she screams, strikes, bites, is 
determined to get away from those who take care of her ; in 
such cases she complains of pressure as though the heart 
would burst and as though she must tear it out of her body. — 
Cactus has violent palpitation, with constrictive, band-like or 
vise-like pressure at the heart, and, like Belladonna, sense of 
great fulness ; but it lacks the violence and intensity of both 
cardiac and mental symptoms of Belladonna. Palpitation 
brought on from mental emotion, with fluttering sensations 
about the heart. Useful when there is cardiac hypertrophy. 
It acts upon the heart muscle, and is of more value as a regu- 
lator of the muscular apparatus than in nervous affections. — 
Camphor (camphor monobromate) is of service chiefly 
through its physiological effect upon the nervous system and 
its usefulness in hysteria. It is a powerful heart stimulant, 
but clinically it must be valued as an antispasmodic. The 
monobromate of camphor has been extensively used in hys- 
teria, usually in five-grain doses, in form of sugar-coated pills 
or in capsules ; it is apt to irritate the stomach. Lilienthal, 
Clarke, and others advise its use (attenuated?) when there is 
palpitation with a full or weak, imperceptible pulse, coldness 
of the surface and collapse, "especially if there is at the same 
time intolerance of external heat" (Clarke). — Cannabis Indica. 
Hysteria, with mental exaltation bordering upon delirium ; 
awakened from sleep by palpitation, with much oppression at 
the heart and dj^spncea; fulness and great oppression at the 
heart, so he wants to be fanned constantly. "Sensation as if 
drops of water were falling from the heart" (Cann. sat.). — 
Coca is a valuable general tonic. It is highly recommended in 
cases of palpitation from overexertion, especially in mountain 
climbing. It should be given in physiological doses. — Coffea. 
Exceedingly valuable in palpitation brought on by mental 
excitement, with general nervous erethism. Great sensitive- 
ness and excitability ; trembling of limbs ; sleeplessness. Occa- 
sionally, when of unmistakably nervous origin, a cup of black 
coffee quickly relieves. The attenuations usually act well. — 
Crocus has palpitation, with anxiety at the heart, with weak- 
ness extending through the whole bod} r to the soles, as if the 
body were sinking down (T. F. Allen), with warmth about the 
heart, emptiness in the precordial region, etc. It has been pre- 



tachycardia — rapid heart. 1117 

scribed for the palpitation of hysteria, with a sensation as 
though some living thing were jumping about in various parts 
of the body; its mental condition is striking; the mood is 
changeable; he scolds, but repents the next moment; uncon- 
trollable laughter. — Glonoine is indicated by throbbing, burst- 
ing fulness of the heart's action, with throbbing fulness in 
the head, great oppression and anxiety; purring noise in 
the cardiac region when lying down; pulse intermittent. — 
Ignatia is rarely of any use during the attack, but not infre- 
quently proves of great service in curing the primary trouble. 
The characteristic mental condition, faintness and goneness at 
the stomach" and gastric disturbances with flatulency are reli- 
able indications for its use. — Lachesis. Intolerance of con- 
striction anywhere and of touch ; trembling and fluttering of 
the heart ; sense of suffocation ; very irregular action of the 
heart ; feeling as if the heart turned over. — Moschus. Palpita- 
tion with much anxiety, apprehension of death, nervous chilli- 
ness, fainting from the slightest cause. In hysterical persons. 
Palpitation of tobacco smokers (?). — Nux moschata. Hys- 
teria ; long intermission of the pulse-beat ; it seems as though 
the heart had stopped "for good." Awful, death-like feeling 
about the heart ; fluttering and trembling, as if from fright ; 
faintness and fainting. — Nux vomica. Frequent and short 
spells of palpitation in dyspeptics of sedentary habits, from 
mental emotion, and with the characteristics of the remedy. — 
Pulsatilla. Useful in the treatment of the primary disease 
rather than of the paroxysm. Characteristic disposition ; pal- 
pitation of moderate degree, but with tendency to their recur- 
rence, in young girls at puberty or with amenorrhoea ; relieved 
by pressure with the hands ; chilliness ; occasional sharp, rheu- 
matic pain at the heart; sense of suffocation. — Sepia. An 
important remedy for the cause of the primary disease ; espe- 
cially useful in women who suffer from derangements in the 
sexual sphere which are covered by Sepia. Tremulous feeling 
in the heart, -with flushing. Worries about trifles, often about 
things that happened long ago and cannot be helped. — Scu- 
tellaria. From emotional excitement; hysteria of -women 
suffering from uterine and ovarian disorder. Sensation of 
throbbing or trembling about the heart ; sticking pain in the 
heart. — Spigelia may be demanded, exceptionally, by severe 



1118 DISEASES OF THE ORGANS OF CIRCULATION. 

sticking or neuralgic pain about the heart, with irregular and 
tumultuous action.— Veratrum album and Veratrum viride. 
The heart is utterly exhausted from long-continued effort ; 
symptoms of collapse ; skin cold and clammy ; pulse intermit- 
tent, slow. Consult also Calcarea, China, Conium, Kali 
carb., Kalmia, Phosphorus, Phosphoric acid, Tabacum, 
Thea. 

ARRHYTHMIA. 

Irregularity' in the heart's action arises from variations in 
the force of successive beats or from irregularity in the inter- 
vals between the beats. To a certain extent this condition is 
not incompatible with health, and cases are on record of 
marked arrhythmia persisting for a long term of years. Baum- 
garten classifies the causes as follows: Central (cerebral), 
either organic (as in haemorrhage or concussion) or pS3^chical 
influences. Reflex, as illustrated in irregular action of the 
heart in dyspepsia or diseases of the lungs, liver, or kidneys. 
Toxic influences, as tobacco, tea, coffee, digitalis, belladonna, 
and other drugs. Changes in the heart itself, either in the car- 
diac ganglia or in the substance of the heart ; the latter are 
usually characterized by dilatation, fatty degeneration, and scle- 
rosis of the coronary arteries. Various forms are recognized, as: 
the pulsus paradoxicus (Kuessmaul), in which, through weak- 
ness of the heart, the blood is not propelled with sufficient 
force through the thoracic blood vessels ; hence an interruption 
of the pulse during full inspiration, reappearing during the ex- 
piration. It is found with compression of the aorta by peri- 
cardial adhesions. — Pulsus intermittens. The rhythm is broken 
by the absence of one or more beats. — Pulsus alternans. Strong 
and weak pulsations alternate regularly. — Pulsus higeminus. 
An irregular pulse with a slight pause after even- second pulsa- 
tion. — Pulsus trigeminus, p. quadrigeminus, p. quinquegemi- 
nus. Irregular pulse with a slight pause after even- third, 
fourth or fifth pulsation. — Pulsus dicrotus. The finger feels 
two distinct blows, one lighter than the other, for each cardiac 
systole, the result of rapid pulsation of the heart and dimin- 
ished arterial tension ; the artery rebounds with each contrac- 
tion of the heart, in addition to the original impulse. — Water 



BRADYCARDIA. 1119 

hammer pulse (Corrigan's). "A jerking, visible, collapsing, 
tortuous and yet regular and rapid pulse, characteristic of 
aortic incompetence with hypertrophy of the left ventricle or 
aneurism of the ascending transverse portion of the arch of the 
aorta, and of disease of the aorta when that vessel has become 
rigid and dilated." — Embryocardia. Foetal heart rhythm 
(Stokes). The character of both heart sounds is alike, and the 
long pause between them is shortened. — Gallop-rhythm, sound- 
ing like the foot-fall of a horse at a canter, from reduplication 
of the second sound of a rapidly beating heart. It is heard 
often in arterio-sclerosis and interstitial nephritis. — Delirium 
cordis. Wholly irregular, tumultuous action of the heart, 
usually found in the late stage of cardiac dilatation associated 
with valvular lesions. 

BRADYCARDIA. 

Bradycardia, brachycardia, or "slow pulse" may be the nor- 
mal pulse of some persons, the term usually being made to 
cover a pulse of less than 60 or 50 beats to the minute. It 
may be physiological or pathological. Physiologically it is 
characteristic of the puerperal state and of hunger. Patholog- 
ically it is found in convalescence from acute fevers, probably 
the result of exhaustion ; in diseases of the digestive system 
(dyspepsia, ulcer and cancer of the stomach), of the respiratory 
system (oftener emphysema), of the circulatory system (fatty 
and fibroid changes in the heart), of the urinary system (occa- 
sionally in nephritis and uraemia), as the result of poisoning 
(lead, tobacco, coffee, digitalis, alcohol); in anaemia, chloro- 
sis, diabetes; in diseases of the brain (apoplexy, epilepsy, hy- 
drocephalus, medullary disease, cerebral tumors, injuries to 
the cervical vertebrae, etc.) and nervous system (chronic disease 
of the spinal cord, myelitis, pachymeningitis, cerebro-spinal 
meningitis); persons suffering from epilepsy or dementia par- 
alytica frequently have an abnormally slow pulse. 

Bradycardia, when associated, as it is in the majority of 
cases, with serious forms of disease, must necessarily be looked 
upon with apprehension. If also arrhythmic and weak, it be- 
comes doubly serious. In organic disease of the heart, as in 
insufficiency of the aortic valves and in mitral insufficiency, the 



1120 DISEASES OF THE ORGANS OF CIRCULATION. 

prognosis is very grave. The same seriousness attaches to it 
in diseases of the brain. 

ANGINA PECTORIS. 

Angina pectoris, stenocardia, sternalgia, breast-pang, is a 
symptom which usualh r occurs in connection with organic 
disease of the heart and vessels (coronary disease and sclerosis 
at the root of the aorta) or of a neuralgic character, consisting 
of an intense, agonizing pain at the heart, frequently extending 
upward into the left shoulder and neck or downward into the 
left arm, associated with a sensation of impending death. 
Two forms are distinguished : true angina, associated with the 
organic changes indicated, and false angina (pseudo-angina), 
neurotic or neuralgic in character. The affection is rare. True 
angina is usually seen in men past fifty years of age; pseudo- 
angina occurs oftener in women, occasionally in children, and 
is frequently associated with other neuroses (listeria, hypo- 
chondriasis, epilepsy); it is often brought on by great physical 
exertion or violent emotional disturbances. A form of angina, 
the result of exposure to cold, has been described by Noth- 
nagel. 

./Etiology. — The aetiology- of angina pectoris is still unsettled 
so far as this embraces exact knowledge of its pathology. For 
practical purposes it is sufficient to bear in mind that in true 
angina obstruction of the corona^ arteries appears alwa3 r s to 
be present, and that this condition directly affects the nutri- 
tion of the heart ; whether the pain is due to anaemia or to 
necrotic processes set up in the heart muscle is still an open 
question. In either case motor weakness exists, and it is not 
difficult to understand that under such conditions any special 
exertion or powerful emotional excitement ma}' readily cause 
intense pain. The irradiations of pain are explained by the re- 
lation of the cardiac plexus to other nerves, and the preponder- 
ance of these irradiations on the left side is held due to the 
fact that the aorta and heart lie on the left side or that the 
attacks may emanate from the left heart. The brain compre- 
hends and appreciates threatening danger, thus giving rise to 
the distressing sensation of impending death, even though the 
pain, as in some cases, may not be excessive. Pseudo-angina 
depends upon hysteria and other neuroses, from reflex causes 



ANGINA PECTORIS. 1121 

(as dyspepsia or other disease of stomach or intestines), from 
the presence of tumors in the neck or chest, aneurism, etc., or 
such affections of the brain or cord as implicate the origin of 
cardiac nerves. Other, and more frequently operative, causes 
are: the abuse of alcohol (whiskey, brandy, absinthe) and 
tobacco, particularly heavy imported tobacco, and of coffee and 
tea. In either form a great physical exertion or violent emo- 
tion may readily act as the immediate exciting cause. 

Symptoms. — Usually the patient is suddenly taken with a 
violent pain in the region of the heart, stabbing, lancinating, 
or crushing, but always agonizing ; -with it there is a sense of 
violent constriction about the heart, as though it were firmly 
grasped in a vise. The pain radiates upward into the (left) 
shoulder, sometimes into the neck and occiput, and downward 
into the (left) arm, often into the hands and fingers; it may 
involve the right side, and frequently is associated with ting- 
ling and numbness in the painful parts, including the heart. 
In the true angina, the patient, uttering a sharp exclamation 
of pain, usually grasps some firm object to support himself or 
rushes to the open window, at the same time making violent 
pressure with the left hand upon the heart. The sensation of 
impending death is overwhelming, and is expressed in the face 
by a leaden, ashy hue ; the forehead is bathed in profuse cold 
sweat ; the attitude of the body is one of rigidity. After a few 
moments the attack may cease as suddenly as it appeared. 
Occasionally the onset is gradual, the paroxysm itself being 
preceded by nausea, ringing in the ears, chilliness, and other 
symptoms of a nervous character. In other cases pain at the 
heart may be comparatively slight, and may be wholly masked 
by the horrible sensation of impending death. The action of' 
the heart usually, but not always, is regular, with greatly in- 
creased tension ; the apex beat generally is forcible and diffuse. 
Respiration may be regular and normally deep ; less often it is 
shallow and jerking. The attack may pass off with copious 
eructations of gas, a movement from the bowels, or voiding of 
large amounts of limpid urine, as after violent attacks of hys- 
teria. Fainting and even fatal syncope may occur during a 
paroxysm of true angina. 

In some instances, the paroxysm having passed, the patient 
is left feeling quite well, though somewhat exhausted ; in 
71 



1122 DISEASES OF THE ORGANS OF CIRCULATION. 

others there is profound prostration. Recurrences take place 
at varying intervals, possibly every few hours, for several 
days; more frequently the patient enjoys excellent health for 
months or years, to be startled by the sudden appearance of 
another attack. 

The so-called vaso-motor angina, described by Nothnagel, is 
the result of exposure to cold, and is characterized by much 
less violent symptoms, so far as pain and sense of impending 
death are concerned, with spasm of the vessels of the extremi- 
ties, coldness, stiffness, numbness and sensory disturbances. 

Diagnosis. — The essential feature of true angina lies in the 
sclerotic or atheromatous changes in the vessels associated 
with cardiac disease, and the diagnosis rests upon the presence 
of arterio-sclerosis, with ringing aortic second sound and high 
arterial tension. It occurs suddenly and usually follows an 
effort of some kind ; attacks occurring in the night during sleep 
are due to organic disease. The appearance of the patient is 
characteristic; he stands rigidly fixed, the hands pressed upon 
the heart, transfixed with pain and alarm, a striking contrast 
to the nervous excitement which almost alwa3^s forms a con- 
spicuous feature of pseudo-angina. True angina resembles 
cardiac asthma, but in the latter dyspnoea is most distressing, 
with tendency to pulmonary oedema and moist rales. Hys- 
terical angina occurs spontaneously, is more frequent in 
women than in men, results from causes which are closely 
related to hysterical affections, and is usually associated with 
emotional disturbances. If equally severe, it is less strictly 
localized ; the action of the heart shows less tension, and par- 
takes more of the character of palpitation ; the patient screams 
with pain, is restless, moves and walks about, and in many 
ways betrays to the careful observer the nervous coloring of 
the paroxysm. The forms of pseudo-angina which depend 
upon poisoning with tobacco or alcohol, or are associated 
with neuroses, are recognized by the absence of the organic 
changes in the heart and vessels which pertain to true angina, 
by anomalies in the action of the heart which are characteris- 
tic of alcohol or tobacco-poisoning, and distinct expressions of 
a neurotic condition. 

Prognosis. — The prognosis is alwa3^s serious. Fatal syncope 
may occur during the first, or any subsequent, attack, and 



ANGINA PECTORIS. 1123 

death from a paroxysm of angina pectoris in the night is com- 
paratively frequent ; the list of sudden deaths thus occurring 
embraces many names distinguished in letters and in the pro- 
fessions. Pseudo-angina is, of course, infinitely less dangerous, 
and a promise of permanent relief may be given if the conditions 
are favorable; but even here a certain measure of reserve is 
admissible. Life may, however, be indefinitely prolonged if 
the patient escapes the operation of conditions which are liable 
to provoke a paroxysm. Exceptionally cures have been made 
of the true organic form. 

Treatment. — The chief aim of persons suffering from angina 
should be to cultivate evenness and deliberation in all they do ; 
worrying and hurrying invites an attack of the disease. It is 
hardly necessary to add that the use of alcohol, coffee, tea, and 
especially tobacco, must be forbidden, and that violent muscu- 
lar exertion is inconsistent -with safety. During a paroxysm 
energetic measures for relief must be applied without an in- 
stant's hesitancy. Of these, the most promising and easiest 
applied is amyl nitrite, of which from two to five drops are to 
be placed upon a handkerchief for inhalation by the patient. 
It affords relief to the heart by causing prompt dilatation of 
the arterioles ; flushing of the face with lessening of tension in 
the arterial system are produced quickly, followed in many 
cases by relief of the pain. If necessary, the use of the amyl 
nitrite may be continued for some little time — a few minutes — 
but it should be stopped unless it acts with reasonable 
promptness. It must be administered while the patient is in 
an upright position. In many cases, if exhibited at once, the 
drug will abort an attack ; hence the wisdom of directing per- 
sons liable to heart-pang to carry upon their person "perles" 
or little glass-tubes filled with the nitrite, which are broken in 
a handkerchief and are thus ready for immediate use. If relief, 
during a paroxysm, is not apparent within a very few minutes, 
chloroform or ether, preferably the latter, should be given. 
Often a few inhalations of either anaesthetic act like a charm, 
and a number of cases have been reported in which the attack 
could always be aborted by a few deep inhalations of ether. 
If still no relief is had, it may be necessary to resort to the 
hypodermic use of morphia, which, however, is objectionable 
in serious affections of the heart. 



1124 DISEASES OF THE ORGANS OF CIRCULATION. 

In addition, counter-irritants may be applied over the heart, 
preferably sinapisms, and in the milder forms and in functional 
angina these or the employment of heat (water at a tempera- 
ture of 140° to 150° F. in a rubber bag) or of cold (ice bag, 
cloths wrung out of ice-cold water) are usually all-sufficient. 
Electricit\ r has proved valuable, especially in idiopathic cases. 
"The positive pole with a broad surface has been placed by 
Eulenburg over the heart and sternum, and the negative on 
the lower cervical vertebrae. The (galvanic) current passed 
between these points was gradually increased until thirty cells 
were brought into the circuit. Von Hiibner placed the positive 
electrode in the supra-sternal fossa, and the negative upon the 
cervical sympathetic ganglia, of first one and then the other 
side; he then moved the positive pole to the lower cervical 
ganglion and the negative to the sensitive spots, at the angles 
of both shoulder-blades. At first, weak currents, from four to 
six elements, were used, but gradually their strength was in- 
creased, and 8 or 10 elements were employed. B\^ most practi- 
tioners not more than 10 or 15 cells are used. The duration 
of the application of the currents must also be gradually in- 
creased. Usually from one to five minutes are sufficient for its 
use." (Davis, in International Sj^stem of Electro-Therapeu- 
tics.) The curative treatment of the dominant school consists 
chiefly of the use of nitro-glycerine, one drop of a 1-per-cent 
solution, two or three times daily, increasing the dose by one 
drop every five or six days until flushing or headache result. 
Stn-chnia and arsenic are also highly recommended. The 
iodide of potassium is thought to exert some specific effect 
upon the arterio-sclerosis, and on this account is exhibited for 
a considerable length of time by Huchard and others. 

Therapeutics. — Aconite is the most valuable remedy in 
vaso-motor angina from exposure to cold, with intense 
anxiety, coldness, pain at the heart radiating in every direc- 
tion, with numbness, tingling, paresthesia. — Amyl nitrite. 
During the paroxysm ; by inhalation ; acts physiologically. — 
Arsenicum. Fatt}^ degeneration ; irritability of the heart 
from smoking or excessive use of tea ; excessive pain at the 
heart, with anxiet}^ and fainting ; worse at night, from 1 to 5 
a. m. — Aurum muriat. Arterio-sclerosis ; fatty degeneration, 
hypertrophy of heart, hypochondriasis, attacks of anguish, 



ANGINA PECTORIS. 1125 

with tremulous fearfulness and restlessness, driving him from 
place to place. — Cactus. One of our best remedies. Increased 
action of the heart, with high arterial tension ; sensation at 
the heart as though it were grasped in an iron hand or crushed 
in a vise. — Cuprum, when there is chronic aortic disease, with 
distress and pain behind the ensiform cartilage. Extreme cold- 
ness all over. Slow pulse, choreic tendency. — Glonoine (Nitro- 
glycerine). Angina pectoris with fluttering of the heart and 
violent beating as though it would burst the chest open, with 
labored breathing, pain radiating upward and downward 
into the arm, with loss of power and numbness. — Kalmia. In- 
tense, neuralgic pains about the heart, extending down the 
left arm, with extreme anguish about the heart ; atheromatous 
condition of the vessels. In persons suffering much from wan- 
dering pains about the heart, with slow, weak pulse. — Oxalic 
acid has been highly recommended by Pemberton Dudley. It 
is useful when the pain is stitch-like, confined to a small spot, 
aggravated from the slightest motion, and accompanied with 
a peculiar numbness all over, almost like palsy. — Spigelia. 
Sudden severe, stabbing, neuralgic pain at the heart, extending 
into the arm, with numbness of the arm. Tumultuous and ir- 
regular action of the heart. In pseudo-angina where the pa- 
tient suffers much from neuralgic pains about the heart, asso- 
ciated with palpitation. — Tabacum. Sudden precordial an- 
guish ; pain radiates from the heart ; death-like faintness, with 
cold face and extremities ; cold sweat all over ; pinched features. 
Inability to lie long on the left side ; paroxysms of precordial 
oppression at night, coming on with such force that he is 
obliged to spring out of bed. 

Consult also : Agaricus (neuralgia about the heart ; from 
excessive use of coffee, tea, tobacco ; associated with symptoms 
of nerve pain at the stomach); Coca (helpful as a general 
nerve-tonic ; lessens the danger of angina arising from physical 
exertion, especially from mountain-climbing); Convallaria 
(heart-tonic; cardiac asthma rather than angina pectoris); 
Lachesis (intolerance of pressure about the heart; sense of 
suffocation; feeling as though the heart were turned over; 
atheromatous arteries; chronic aortitis); Cimicifug a (wander- 
ing pains about the heart); Kali iod. (to overcome arterio- 
sclerosis ; must be continued for a long time); Nux vomica and 
Strychnia. 



1126 DISEASES OE THE ORGANS OF CIRCULATION. 



DISEASES OF THE BLOOD-VESSELS. 

DISEASES OF THE ARTERIES. 

ACUTE ARTERITIS. 

A rare affection, usually occurring in the course of acute in- 
fectious diseases, as the result of general intoxication. It 
closely resembles endocarditis. There is more or less thicken- 
ing of the intimae, with fibrinous deposits greatly varying in 
size, and occasional tendency to ulceration. 

The symptoms are indefinite. There is usually considerable 
palpitation and throbbing of the vessels, with pain in the 
arch of the aorta, of severe and stabbing character, substernal 
tenderness and soreness or, in some cases, uneasiness and pain 
in the right shoulder. A moderate fever is common. 

The diagnosis is uncertain. The affection is not readily differ- 
entiated from endocarditis; a larger area of pain of greater in- 
tensity, with absence of murmur at the apex, point to arteritis. 
A tendency to fatal embolism — indicated by the occurrence of 
rigors or severe chills — and to rupture of the vessel renders the 
prognosis very serious. 

The treatment is that of endocarditis. Absolute rest, a mod- 
erate diet, cold applications to the chest and cardiac sedatives 
are of particular importance. 

ARTERIO-SCLEROSIS. 

A condition of induration of the -walls of an artery, chiefly in 
the musculo-elastic coat, developing slowly, characterized by 
simple thickening of the intimae or "resulting in its replacement 
in patches of atheromatous or calcareous material, or in impli- 
cation of the media and adventitia ; in extreme cases convert- 
ing the vessel into a cord of bony stiffness." (Foster.) The 
terms arterio-capillary fibrosis, arteritis deformans and ather- 
oma are used by authors in describing this condition. 

/Etiology. — Arterio-sclerosis occurs rather oftener in men 
than in women, and is more frequently seen in persons who 
have passed middle age than in the young. In fact, it is a 



ARTERIOSCLEROSIS. 1127 

very common feature of old age, the result of the long-continued 
use or of inherited weakness and poor quality of the arte- 
rial tissue ; the latter accounts for the tendency to this affection 
which is observed in some families, and which in such cases 
may show itself in the young. Renal disease is intimately con- 
nected with arterio-sclerosis, but their exact relation is not yet 
understood ; it is probable that in the greater number of cases 
the blood vessels are primarily diseased. Among the constant 
etiological factors are habits of life which throw an unusually 
severe strain upon the blood vessels by raising the blood pres- 
sure and increasing peripheral resistance. Such are chiefly 
habitual over-use of muscles in athletics or in laborious occu- 
pations, particularly when these involve long-maintained 
cramped position which interferes with freedom of circulation, 
as is the case with miners. Over-eating, also, especially in 
large persons of indolent habits, is thought to lead to arterio- 
sclerosis by keeping the blood vessels overfilled. In a large 
number of instances, notably among young people, the disease 
is the result of chronic intoxication, especially the intoxications 
of alcohol, syphilis, lead and gout. Less frequently it is asso- 
ciated with diabetes, malaria, or with acute infectious diseases 
(typhoid fever, scarlet fever, small-pox) or the cachexia of 
cancer and tuberculosis. 

Morbid Anatomy. — Arterio-sclerosis is usually seen in the 
larger arteries, oftenest in the aorta, especially in the ascending 
portion of the arch ; next in order of frequency come the iliac 
and femoral, the brachial, radial and ulnar, the coronary 
arteries and the arteries of the brain ; it is rare in the gastric, 
hepatic and mesenteric. Small arteries may also become ather- 
omatous. Exceptionally the veins are affected. 

Thoma distinguishes a primary and secondary form. In the 
former, dilatation of the vessel and compensatory increase of 
the connective tissue of the intimae follow local changes ; in the 
latter, the same compensatory effort is brought about by more 
diffuse changes in the vessels which are the result of increased 
peripheral tension. The atheromatous process itself is charac- 
teristic and can be readily seen with the naked eye. The 
intima is covered with grayish thickenings and elevations, 
irregular in shape, and of varying size; they occur oftenest at 
a point where a smaller vessel branches off. These thickened, 



1128 DISEASES OF THE ORGANS OF CIRCULATION. 

nodular spots may be gelatinous or fibrinous or hard and cal- 
cified. If the latter, and if the plates formed are numerous, the 
entire vessel may become stiff and tube-like. In these localized 
changes the tendency is to necrosis (atheromatous abscess) 
and ulceration (atheromatous ulcer). Microscopical^ the 
intima is seen to be swollen, chiefly from extensive new growth 
of its connective tissue ; not rarely there is superficial degenera- 
tion of the intimas, while in the deeper layers extensive break- 
ing-down of tissue takes place, with the formation of the ather- 
omatous abscess or ulcer or of calcification plates. Similar 
changes, less marked than in the intimae, are seen in the media 
and adventitia. When there is much localized dilatation, the 
media and adventitia may be thin, atrophied or degenerated. 
The process is practically a local circumscribed inflammation 
(mesarteritis and periarteritis) with resultant weakening of 
the wall of the vessel and compensatory thickening by pro- 
liferative changes in the intimae at the seat of the weakening. 
If the latter, compensatory process is dela^^ed, dilatation and 
aneurism may develop rapidly. 

The diffuse form of arterio-sclerosis is oftenest seen in persons 
of middle-life and younger, especially in those of fine muscular 
development, and is more common in negroes than in whites. 
It may involve the aorta and its branches, but oftener occurs 
in the smaller arteries. Microscopically no striking changes 
may be observed, though the intima may be covered with 
slightly elevated, opaque spots which may present character- 
istic atheromatous changes. Microscopically the median coat 
of the vessel shows extensive necrotic and hyaline changes, 
with a corresponding compensatory increase in the subendo- 
thelial connective tissue. Nodular formations may, or may 
not, be found here. The smaller arteries in these cases may be 
extensively involved, the most striking changes consisting of 
thickening of the wall from hyaline formations within the 
muscular coat, often complete or partial disappearance of the 
elastic laminae, atrophy of the muscular fibres in the media, 
and pronounced tendency to fatty degeneration of structure. 
Affections of the heart are common in these cases, including 
great increase of weight of the heart itself, fibrous myocarditis, 
sclerosis and incompetency of the semilunar valves. 

In the senile form, there is extensive dilatation and tortu- 



ARTERIO-SCLEROSIS. 1129 

osity of the vessels. The walls usually are thin but stiff, and 
the vessel is rigid like a tube. Calcareous deposits frequently 
are very extensive, often occupying a large portion of the inner 
coat of the vessel. Atheromatous abscesses and ulcers, from 
degeneration of the subendothelial tissues, are common. The 
liver and kidneys are usually atrophied, and the heart and 
other organs may show the structural changes characteristic of 
old age. The occurrence of atheromatous changes in a vessel 
necessarily implies loss of elasticity in the wall of the vessel 
and lessened powers of resistance to the blood-pressure ; hence, 
danger of aneurismal dilatation until compensatory thicken- 
ing has taken place, which, according to Thoma, is established 
in a year at about the fortieth year of life. If the degenera- 
tion is extensive, hypertrophy of the left ventricle is often seen, 
due to the extra work thrown upon it by the increased resist- 
ance in the affected vessels to the blood current and by their 
inability to assist in the propulsion of the blood. Nutritive 
disturbances in distant organs may result when the lumen of 
the vessel is greatly lessened by extensive thickening of the 
intima and by the formation of thrombi on the atheromatous 
structures. 

Symptoms — The existence of arterio-sclerosis very often is 
not recognized during life, owing to the absence, in many cases, 
of any marked disturbances in the general health, and because 
of the indistinctness of such signs and symptoms as belong to 
it. The most reliable indications are derived from examination 
of the peripheral arteries, with increased arterial tension and 
cardiac hypertrophy. 

The larger peripheral arteries (radial, femoral, temporal) in 
arterio-sclerosis usually feel hard, bony and "spiral," like the 
neck of a bird. It must, however, be remembered that an 
atheromatous state of these superficial vessels may be clearly 
demonstrated, while the internal arteries are free from disease ; 
the reverse may obtain. The typical pulse is the pulsus tardus; 
the pulse wave is slow and sluggish in ascent and descent; 
during the intervals between the beats the vessel is firm, full, 
incompressible, and the hardness of the walls is at times 
such that firm pressure persistently exercised cannot obliterate 
the pulse at the wrist; in extreme cases of calcification no 
pulse may be detected. The sphygmograph "shows a gradual 



1130 DISEASES OF THE ORGANS OF CIRCULATION. 

ascent with a broad top and sustained wave. The tidal wave 
is often very marked, and the dicrotic notch, as a rule, indis- 
tinct and obliterated." Enlargement of the left ventricle of 
the heart is the logical result of the great amount of work 
which it must perform ; it is associated with the physical 
signs peculiar to it, namely : increasing displacement down- 
ward and outward of the apex beat; heaving and forcible 
impulse; distinct accentuation of the second aortic sound; 
often a sensation of fulness about the heart. As in valvular 
disease, compensation once established and maintained, the 
general health ma}^ remain excellent for an indefinite length of 
time ; occasionally symptoms of slight renal disturbance, as 
transient albuminuria, arrest the attention of the patient. 
Eventually, however, in the greater number of instances, 
the general health fails and distressing symptoms occur, 
either depending upon serious involvement of the heart or 
upon some disturbance set up in a distant organ. 

In some cases cardiac insufficiency, followed by dyspnoea, 
serous effusion, etc., eventually declares itself. If the coronary 
arteries are involved, difficulty of breathing, sense of fulness at 
the heart, more or less pain, and finally true angina pectoris 
are not infrequent ; there is also danger of fibroid degeneration 
of the heart, aneurism, myomalacia, rupture of the heart, or 
sudden death from thrombosis. Cerebral symptoms may de- 
velop. Headache, ringing in the ears and vertigo, sometimes 
attended with fainting and epileptiform seizures, are fre- 
quently seen ; in fact, the lighter of these symptoms may per- 
sist throughout the course of the disease. Among the transi- 
tory symptoms experienced are palsies, aphasia and disturb- 
ances of vision. Degenerative changes occur, often preceded by 
disturbances in the intellectual sphere and loss of memory. 
Haemorrhage usually is observed late, but may take place 
before there is evidence of degeneration. Renal disease is 
common in senile arterio-sclerosis and in the diffuse form of 
younger persons; it usually assumes the expression of con- 
tracted kidney. Other conditions more or less intimately asso- 
ciated with arterio-sclerosis are : gangrene of the extremities, 
bronchitis, emphysema, and cirrhosis of the liver and pancreas. 

The diagnosis depends upon the presence of thickening of the 
peripheral arteries, persistent high arterial tension, enlarge- 



ARTERIOSCLEROSIS. 1131 

ment of the heart, and the age of the patient. It involves a 
careful study of the entire case, and is likely to be presumptive 
in very many instances. Differentiation of the cardiac symp- 
toms which are peculiar to this state from those of valvular 
disease is both difficult and of slight practical value, since the 
treatment is the same. 

The prognosis, as to life, is favorable, for, as in valvular dis- 
ease of the heart, persons suffering from arterio-sclerosis may 
live to old age. The danger arising from cerebral, cardiac and 
renal complications is, however, sufficiently serious to warrant 
apprehension. A cure of the disease, once well established, and 
with sclerotic changes in the walls of the vessels, appears to be 
out of the question. 

Treatment. — The difficulty of recognizing arterio-sclerosis in 
the early stage is so great that the question of treatment rarely 
arises at this time. If, however, the diagnosis is reasonably 
certain, pains should at once be taken, especially in persons of 
more advanced years, to place the patient in a position which 
may enable him to resist and overcome the existing tendency. 
It is well known that persons who suffer from this affection 
are much given to fretting and worrying, and clinicians lay 
much stress upon measures calculated to avoid and overcome 
this ; hence the necessity of insuring to these people freedom 
from anxiety, a large amount of restful and refreshing sleep, 
and a diet which is absolutely simple, easily assimilated, nour- 
ishing and, above all, non-stimulating. The condition of the 
skin, bowels and kidneys should be brought as near as can be 
to perfect health. If there is a sense of uneasiness and muscu- 
lar weakness about the heart, cardiac stimulants may be indi- 
cated ; but they should be used only when positively demanded. 
A milk-diet is warmly advocated when there is renal trouble. 
If the patient be syphilitic, a course of iodide of potassium sug- 
gests itself. Huchard, Sansom, and many others, firmly main- 
tain that the iodide of potassium or sodium, given persever- 
ingly, even for a period of from two to four years, exerts a 
most desirable effect upon arterio-sclerosis, particularly when 
there is angina pectoris. Sansom even admits that under this 
treatment a complete restoration to health may be had, pro- 
vided the treatment be commenced sufficiently early. 

When the case has advanced, the treatment must be largely 



1132 DISEASES OF THE ORGANS OF CIRCULATION. 

symptomatic. If there are complications or affections of the 
heart, kidneys or brain, treatment must be directed to these. 

ANEURISM. 

An aneurism is a localized dilatation of an artery, through 
which blood passes. This dilatation, as the term is here used, 
may include rupture of one or more coats of the blood vessel 
or it may be due to stretching of the wall of the vessel. Many 
forms are recognized ; for a study of these, special works must 
be consulted. 

./Etiology. — Aneurism may occur at any period of life, even 
in the very young, but is found oftenest in middle life, from 35 
to 50 years of age. It is more frequently observed in men than 
in women, undoubtedly because men in their daily vocation 
are much more liable to be under the operation of conditions 
which may prove immediate exciting causes. The two essen- 
tial factors in the causation of aneurism are : diminished re- 
sistance of the wall and increased blood pressure. The former 
may, and very commonly does, arise from an atheromatous 
condition of the vessels, i. e. degeneration of the media, and, as 
pointed out under arterio-sclerosis, is greatest prior to the es- 
tablishment of compensatory thickening of the intima. Aneur- 
ism in the arch of the aorta is commonly due to this cause. 
The same weakening of the wall of the vessel may be caused by 
laceration from a calcified embolus or by inflammatory action 
and subsequent softening, set up by an infected embolus or 
thrombus. Mycotic influences are occasionally at work, as in 
malignant endocarditis, and aneurism from this cause is now 
fully recognized. An. inherited predisposition to weakness of 
the walls of the blood vessels undoubtedly exists, and is proved 
from its occurrence, in successive generations, in certain fami- 
lies. Syphilis, alcoholism, gout and rheumatism are also im- 
portant factors. Under such conditions anything that raises 
the blood pressure may act as the immediate, exciting cause. 
Not only are persons engaged in occupations which demand 
great muscular exertion, as blacksmiths, sailors and miners, in 
especial danger of developing aneurism, but the weakened 
walls of a vessel may give way from the increased pressure 
brought about by violent straining at stool or a severe fit of 



ANEURISM. 1133 

coughing. Violence is an important factor in aneurism of the 
peripheral arteries. 

Morbid Anatomy. — Aneurisms naturally divide themselves 
into the circumscribed and diffuse. Of the former, the "saccu- 
lar" and the "fusiform" variety are the most common and 
typical; they vary greatly in size, from a millet seed to the 
size of a fist or the head of an infant, and in numbers. A diffuse 
aneurism, as the term indicates, is the extensive aneurismal 
dilatation of a blood vessel, often involving its branches ; it is 
"tortuous" or "serpentine" in appearance; hence the term 
"cirsoid" or "serpentine." The "dissecting" aneurism consists 
of a partial rupture within the vessel, the blood "dissecting" 
its way between the tunics. Wm. Pepper describes a case in 
which "there was a transverse rupture of the media and intima 
near the aortic valves, from which the blood had gradually 
found its way along the entire length of the aorta, and by 
secondary ruptures into the aorta just above the bifurcation, 
and into one of the iliac arteries. There were practically two 
aortas side by side, separated by a narrow partition." Rich- 
ardson, of Toronto, relates a similar case. An artery may 
communicate with a vein ( art erio -venous aneurism); if di- 
rectly, it is an aneurismal varix ; if by a sac, it is described as 
a varicose aneurism. 

The wall of an aneurism at first is composed of all the coats 
of the vessel ; sooner or later the middle tunic yields and disap- 
pears, the intima and adventitia become thickened and adherent 
to each other, eventually forming one fibrous tissue. The intima 
often shows extensive degeneration and calcification. If 
eventually the wall yields and ruptures, the surrounding 
tissues form an adventitious wall or covering. The contents 
of the aneurism consist, in part, of clotted blood, which may 
be the means of a spontaneous cure. Its free surface is dark 
red and, usually, ribbed ; the part of the clot which rests upon 
the wall is pale and brittle, and covered with elastic layers of 
pale reddish color. It is partly organized and subject to degen- 
erative changes, softening and breaking down, and calcareous 
infiltration. It may give rise to emboli or to occlusion of the 
vessels. Communication between the aneurismal sac and the 
artery from which it arises is maintained by an opening of va- 
rying size, round or slit-shaped. 



1134 DISEASES OF THE ORGANS OF CIRCULATION. 

As the aneurism increases in size, it encroaches upon adjoin- 
ing structures and organs, and may give rise to intense pain 
by pressure upon nerves, to distortion and obliteration of 
vessels by pressure upon branch arteries, to the formation of 
thrombi in veins, and to erosion and even absorption of bon\'- 
structures. 

ANEVRI§m OF THE THORACIC AORTA. 

The thoracic aorta is the seat of aneurism in about 74 per 
cent, of all cases of aortic aneurism. It is stated that in more 
than one-half of all cases of aneurism of the thoracic aorta the 
ascending portion is the seat of the affection ; the arch, in 
about one-fourth, and the descending portion in about one- 
eighth of all the cases, the frequency of aneurism lessening with 
increasing distance from the heart. The larger portion of the 
victims is furnished b\ T persons of full muscular development 
and in occupations which demand great muscular exertion, espe- 
cially syphilitics and alcoholics. The accident occurs usually 
in the earlier stages of arterio-sclerosis, prior to the full estab- 
lishment of compensatory thickening of the intima. The 
aneurismal sac varies greatly in size and shape ; it is oftener as 
large as a fist or an apple. The largest are seen in the ascend- 
ing portion, usually are saccular, and occasionally perforate 
the anterior chest wall, appearing as a large external tumor. 
In the transverse portion fusiform dilatations are more fre- 
quent^ noted, and the origin of vessels arising from it is liable 
to be involved. If the aneurism occupies the descending por- 
tion of the arch, there may be compression of the trachea and 
bronchi from aneurismal sacs. In the ascending and trans- 
verse portion of the arch the seat of the aneurism almost 
always is on the anterior, in the descending portion of the 
arch on the posterior, surface, i. e. at a point where the blood 
current most forcibly strikes the wall of the vessel. 

Symptoms. — Aneurism may exist and cause no symptoms 
whatever, but as soon as the tumor becomes sufficiently large 
to cause pressure upon the adjacent structures, the so-called 
"pressure S3 r mptoms " are developed. Aneurism of the ascend- 
ing portion of the arch, if just above the sinuses of Valsalva, is 
usually small, and on this account causes no symptoms ; rup- 



ANEURISM OF THE THORACIC AORTA. 1135 

ture into the pericardium may take place, with immediately 
fatal results. If higher, they are larger, and sometimes attain 
to great size, even producing large external tumors, usually 
making their way outward at the second or third interspace 
by producing erosion of the ribs and sternum. Occasionally, 
smaller aneurisms, by causing dilatation of the orifice of the 
aorta or dragging upon the valves, give rise to symptoms of 
aortic insufficiency. Pressure upon the superior vena cava 
causes venous congestion of the face, neck and arms ; upon the 
subclavian, enlargement of the right arm, with oedema. Per- 
foration into the superior vena cava is indicated by the sudden 
appearance of cyanosis and oedema. If the aneurism is large 
enough to dislocate the heart downwards and to the left, com- 
pression of the inferior vena cava may cause oedema of the feet 
and ascites. Pressure upon the azj'gos vein causes hydro- 
thorax. Pressure upon the recurrent laryngeal nerve gives 
rise to paralysis of the right vocal cord. Pressure upon the 
sympathetic, by irritation of the nerve fibre, produces dilata- 
tion of the right eye; if the fibre is paralyzed, contraction 
follows. Pain is frequently present; it occurs in paroxysms or 
is persistent, and is of neuralgic, stitch-like or anginoid char- 
acter. Death usually occurs from rupture into the pleura or 
superior vena cava; less often from rupture externally or 
heart-failure. Aneurism of the transverse portion is asso- 
ciated with many remarkable pressure signs, especially as 
there is marked protrusion toward the spine encroaching upon 
the trachea and oesophagus. Pressure upon the trachea gives 
rise to dyspnoea of a stridulous character (or asthmatic) and 
may be attended with tracheal and bronchial congestion or 
catarrh, even with blood-streaked expectoration. Compres- 
sion of a bronchus is followed by cough, difficult breathing, 
retention of secretion, suppuration, and sometimes gangrene. 
Pressure upon the oesophagus and thoracic duct causes diffi- 
culty of swallowing, particularly of solid food ; the use of the 
sound in such cases may rupture the aneurism, with fatal 
result. Pressure upon the left recurrent laryngeal nerve causes 
suffocative spells, hoarseness, paralysis of the left vocal cord, 
and aphonia. Pressure upon the sympathetic, dilatation, then 
contraction, of the pupil. CEdema of the left half of the head, 
neck and of the left arm follows involvement of the left in- 



1136 DISEASES OF THE ORGANS OF CIRCULATION. 

nominate. The orifices of the vessels arising from the trans- 
verse portion of the arch may be dilated, or the vessels ma}' be 
compressed or obstructed by thrombi. The radial or carotid 
pulse, in case of such involvement, is retarded or absent, and 
the difference between the pulse on the right and left side easily 
distinguished. The aneurism often reaches a large size, grow- 
ing forward, eroding the sternum, and forming an external 
tumor ; or it may for years lie between the vertebras and the 
sternum. Aneurism of the descending portion is characterized 
by less general pressure symptoms, although compression of a 
bronchus and of the lung is not unusual and occasions serious 
results. Pain, however, is very marked, especially when ero- 
sion of the vertebra? takes place. It is usually felt in or about 
the left shoulder, and is due to erosion of the vertebrae and to 
a neuritis of implicated spinal nerves. Dysphagia is often 
severe. The tumor occasionally appears externally, in the 
scapular region, and may be of enormous size. Among the 
accidents likely to occur are paralysis from compression of the 
spinal cord and death from rupture into the oesophagus or 
pleura. 

Pain is present in many cases ; it is absent in others where 
the aneurism has existed for mam' years and has reached great 
dimensions. A sudden, tearing pain in the upper thorax ma}' 
be felt when the vessel is injured from a violent effort. It is 
usually due to stretching of, or pressure upon, some nerve fila- 
ment. It may be constant, with periods of exacerbation when 
the blood pressure is raised, or sharp, lancinating, shooting, 
and referred to some distant part. The neuralgic element pre- 
dominates, and there may be anaesthesia of the skin and a con- 
siderable loss of power in the parts to which the pinched nerve 
is distributed. A constant dull, boring pain is indicative of 
erosion of bone. Anginal pain indicates nearness of the aneur- 
ism to the heart. Dyspnoea also is frequently present, depend- 
ing upon pressure against the trachea, bronchi, lungs or nerve- 
trunks. The serious effect of compression of a bronchus has 
been discussed ; in such cases large sibilant or sonorous rales 
are usually present. Asthma is present when branches of the 
vagus are implicated, associated with involvement of cardiac 
filaments or gastric branches. Laryngeal symptoms are ob- 
served in a large number of cases. Both sides may be affected, 



ANEURISM OF THE THORACIC AORTA. 1137 

but the left side much oftener. If only one of the vocal cords is 
paralyzed, speech may not be involved. The appearance of the 
patient may not undergo any noticeable change if there is 
little pain; if there is much pain, the face soon assumes a 
drawn and anxious expression. There is much emaciation 
when there is obstruction of the oesophagus and thoracic duct, 
and fever when there is pressure upon the lungs or bronchi. 

Physical Signs. — It is to be remembered that physical signs 
are not to be expected when the aneurism is deep-seated. In- 
spection will necessarily prove the more valuable as the aneur- 
ismal tumor appears externally. It is oftenest seen in the sec- 
ond or third interspace to the right of the sternum or through 
the sternum, and is then usually quite large ; if on the descend- 
ing portion of the aorta, it is at the back, between the spine 
and the left scapula. The pulsation may, however, be distin- 
guished when there is no external presentation of an aneur- 
ismal tumor. It often consists of a diffuse impulse, heaving in 
character, which in some cases is readily observed, in others can 
only be noticed when the chest is narrowly watched and looked 
at obliquely. If the aneurism is on the arch, the pulsation is 
sometimes felt in the root of the neck, occurring a moment 
later than the systole of the heart. In some cases the hand 
may feel a slight systolic thrill in the tumor. A large external 
tumor presenting, pulsation may be noted both from below up- 
ward and laterally. Large external aneurismal tumors are 
covered with a very thin, at times necrotic, layer of skin ; if 
ruptured, the laminas of the sac are exposed. Dislocation of 
the apex beat of the heart downward and to the left from dis- 
location by pressure may be observed. Palpation takes ob- 
servance of the systolic thrill, which is especially marked when 
the arch is much dilated, and of the diastolic shock, which is 
usually communicated to the hand and is felt plainest when 
the aneurism is near the root of the aorta ; it determines the 
location and expansiveness of the pulsation. The impulse is 
slow, strong, heaving, expansile. The latter quality is easily 
perceived when the hand can grasp the external tumor ; when 
this is impossible, the expansile character of the pulsatidn, as 
Pepper points out, may be demonstrated by ' 'placing pieces of 
paper edge to edge upon the skin, when the papers are seen to 
separate a little with each pulsation." The presence of many 
72 



1138 DISEASES OF THE ORGANS OF CIRCULATION. 

or large clots necessarity interferes with this sign. Percussion 
yields no results until the tumor is fairly large and near the 
surface, and cannot even then aid in determining its size, since 
a considerable part of it will be covered by the lung. The area 
of dulness is usually to the right of the sternum and above the 
third rib. The percussion note is flat, and there is a feeling of 
increased resistance. Auscultation is negative when the sac is 
occupied by extensive coagula. A soft systolic murmur is 
sometimes heard over the aneurism, from eddies which form in 
the aneurismal sac. Vibration of the walls of the aneurism oc- 
casionally produces a systolic sound. A systolic murmur may 
be heard over the trachea, probably the result of the expulsion 
of air at each distension of the sac. A diastolic murmur usually 
accompanies insufficiency of the semilunar valves. 

The Pulse. — The mechanical slowing of the blood current in 
the involved arteries and in the vessels beyond the aneurism is 
responsible for the great difference in the force and rapidity of 
the pulse on the two sides of the body ; this is easiest observed in 
the radial pulse. Osier calls attention to the obliteration of the 
pulse in the abdominal aorta and its branches from aneurism of 
the thoracic aorta. Sphygmographic tracings show no constant 
peculiarities. The up-stroke is usually very oblique, and the 
height of the curve reduced. "Tracked tugging" (Oliver) is ob- 
tained as follows : "Place the patient in the erect position, and 
direct him to close his mouth and elevate his chin to almost 
the full extent ; then grasp the cricoid cartilage between the 
finger and thumb, and use steady and gentle upward pressure 
on it, when, if dilatation or aneurism exist, the pulsation of 
the aorta will be distinctly felt transmitted through the 
trachea to the hand." This sign is valuable in deep-seated 
aneurism. 

Diagnosis. — The difficulty of making a diagnosis of a small 
or deep-seated aneurism is evident. Solid tumors, especially of 
the mediastinum, sternum and base of the neck, and particu- 
larly when they project externally and are pulsating, may pre- 
sent difficulties that are practically insurmountable. It is then 
necessary to bear in mind that in tumors there is rarely found 
a ringing second sound and that the pulsations lack the force 
and the expansile character, as well as the diastolic shock, 
which belong to an aneurism ; neither is the "tracheal tugging" 



ANEURISM OF THE THORACIC AORTA. 1139 

present in tumors; pressure phenomena, also, are less common. 
On the other hand, the history of the case may offer valuable 
help ; thus, while aneurism more often occurs in vigorous, mus- 
cular men, frequently of a syphilitic taint, the subject of an ad- 
vanced tumor is usually cachectic and may present such indica- 
tions of malignant disease as secondary nodules in the axillary 
and cervical glands. Pulsating pleurisy lacks the heaving im- 
pulse and diastolic shock ; there is a history of pleural effusion, 
an absence of pressure symptoms, and powerful throbbing 
which may move the whole side. Dislocation of the heart and 
aortic insufficiency may give rise to special symptoms which 
render it practically impossible to differentiate them from 
aneurism. 

Prognosis.— The prognosis is serious, and death may occur 
at any time from rupture or complications. Statistics seem to 
show that the duration of life, after the appearance of the first 
definite symptoms, rarely exceeds eighteen months. A good 
condition of general health has an important bearing upon the 
case. The most hopeful cases are those of sacculated aneurism 
of the ascending portion of the arch ; they run a more deliberate 
course, and spontaneous cures from hardening of a clot and 
subsequent shrinkage of the walls of the sac occur more fre- 
quently here than elsewhere. In the majority of cases, but not 
in all, rupture is soon followed by death. Pressure upon the 
trachea, oesophagus or bronchi indicates an early, fatal termi- 
nation. 

Treatment. — Spontaneous cures are occasionally brought 
about by clotting of the contents of the aneurismal sac andsub- 
sequent contraction of its wall; treatment aims to produce the 
same results. Valsalva's method, modified by Tuffnel, consists 
of absolute rest and greatly restricted diet, including drink, 
maintained for a period of three to four months. The object is 
to reduce to the minimum the action of the heart and the blood 
pressure, and by almost starving the patient to lessen the vol- 
ume of blood and to increase its coagulability. The latter is 
also favored by the small amount of liquid allowed and, if the 
patient's condition warrants it, by the abstraction of from six 
to ten ounces of blood every fortnight. Heart-sedatives and 
narcotics for the relief of pain may be employed if indications 
for their use arise. The practical difficulties of this method, 



1140 DISEASES OF THE ORGANS OF CIRCULATION. 

especially in those not very robust, are evident, and it is al- 
most always necessary to compromise by placing the patient 
upon this restricted diet for a few weeks, gradually returning 
to more generous feeding. The so-called low diet consists of a 
daily allowance of ten ounces of bread, six ounces of farinaceous 
pudding, one ounce of butter, and one pint of milk, divided 
into three meals, fish or broiled meat being added from time to 
time, if the diet be insupportable by the patient. The dry diet 
consists of four ounces of bread, one-half ounce of butter, and 
two ounces of milk, for both breakfast and supper, and three 
ounces each of meat and bread and one ounce of milk for din- 
ner. Here, as in all cases of aneurism, it is advisable to keep 
the bowels open and to avoid straining at stool. 

The use of st\ r ptics and chemicals for the purpose of coagu- 
lating the contents of the sac has practically been abandoned 
as ineffective and dangerous ; the same applies to the introduc- 
tion, into the sac, of horse hair, wire, needles, etc. The elec- 
tric current, however, has in some cases proved capable of 
effecting a cure. Its application is as follows : "Obviously, an 
aneurism of the aorta, or in the iliac or femoral arteries, is 
much more serious than in smaller vessels. The location and 
probable extent should guide us in the treatment. An aneurism 
of the ascending aorta, for example, could only be reached and 
treated through the chest walls. Electrolysis offers the only 
surgical relief. In acting upon the blood stream in this class of 
tumors, only the galvanic anode should be used in the tumor. 

" We will suppose that we have to deal with an aneurism in 
the popliteal space, which is a frequent seat of these tumors. 
It must be differentiated from malignant disease of the bone, or 
an affection of the joint, not a difficult matter, unless it has 
become diffused or broken down, when amputation may be 
necessary. Having diagnosed the tumor as an aneurism, the 
patient will be laid prone and the limb elevated as much as pos- 
sible. The battery being in readiness, apply the cathode to the 
limb, or at some convenient place ; cleanse the space ; have an 
assistant make firm pressure on the artery both below and 
above the tumor ; thrust three or four of the platinum needles 
boldly into the tumor ; turn on a current of from twenty to 
thirtv milliamperes, and let it run for fifteen or twenty minutes, 
or longer if necessary. Take plenty of time. Let the tumor feel 



ANEURISM OF THE THORACIC AORTA. 1141 

solid before removing the needles. If your insulation be per- 
fect, there will be but little discomfort ; so do not hurry. When 
the clot has fully formed, turn off the current ; reverse the poles 
by means of the pole changer on the battery ; then again turn 
on the current for one or more minutes, or until the needles 
may readily be removed. The reason for this reversal is, that 
the clot formed by the anode is very dense and firm, the needles 
are firmly imbedded in it, and, if forcibly removed, bleeding 
will follow. By reversing the current-flow and having the neg- 
ative current on the needles, the clot immediately on them will 
be electrolyzed off, and they will become free. 

"Before attempting any such operation, the beginner should 
practice with the needles in freshly drawn blood, in egg-albu- 
men, and in other coagulable substances, in order to familiarize 
himself with the different actions of the poles. The coagula at 
the cathode will appear frothy, be full of bubbles of hydrogen, 
easily broken down and loosened ; while that at the anode, will 
be firm, adherent, and hold well together. For this reason, the 
anode is preferred for aneurismal operations. 

"It is not necessary to make the pressure, before directed ; only 
if properly done, it will facilitate the operation. The sac must 
be kept full. If the pressure be uneven this may not be done, 
when it will be better to dispense with it. There is little danger 
of embolism where the anode is used, and the treatment of an 
aneurismal tumor, wherever found, if amenable to the electric 
current, will be practically that just laid down. The larger the 
sac, the longer it will take to form a clot sufficient to close, or 
nearly close, the enlargement. 

"Only an experienced person should attempt galvano-punc- 
ture for an aneurism of the aorta or for such a lesion in the 
large abdominal vessels. Axillary aneurism, if not diffused, 
will be treated in the same way. Indeed, for all ordinary le- 
sions of this character galvano-puncture is the ideal method of 
treatment." (Walling, in International Syst. of Electro-Thera- 
peutics.) Loreta's method consists of passing "several feet of 
fine silver wire through a hypodermic needle directly from the 
spool, so that the wire curls up within. This is attached to 
the positive pole, the negative being connected with a surface 
pad or with an insulated needle introduced into the sac. A cur- 
rent is then passed through as in the method of simple gal- 
vano-puncture." 



1142 I DISEASES OF THE ORGANS OF CIRCULATION. 

Any of these methods are applicable only in aneurisms of 
moderate dimensions. 

Venesection maj r be practiced advantageously if there is great 
venous congestion to the head and arms or if dyspnoea is exces- 
sive, with great lividity ; it is said also to relieve the pain. If 
the tumor is external, an ice-cap may prove of use. Iodide of 
potassium, five to fifteen grains daily, is credited with having 
accomplished excellent results even in non-syphilitic cases, but 
its modus operandi has not been explained. Of other remedies, 
Aconite alone, in the hands of the dominant school, appears 
to be generalh- recommended, largely because of its action upon 
the heart. Digitalis, if used at all, must be given in exceedingly 
small doses ; its physiological action may readily cause rupture 
of the aneurism. Complications and emergencies must be met 
as they arise. Pain must be relieved by morphia, chloroform, 
ice, venesection. 

Aconite, Digitalis, Veratrum viride, and other remedies, 
may be indicated from time to time by especial conditions. 

ANEURISM OF THE PULMONARY ARTERY. 

Aneurism of the pulmonary artery is rare. It is associated 
with disturbances of the lesser circulation (phthisis, emphy- 
sema, mitral disease, etc.). In such cases dilatation of the main 
trunk may be great ; it is usually accompanied with relative in- 
sufficienc\- of the semilunar. Atheromatous changes may occur 
in the artery, resulting in aneurism, more often of the saccu- 
lated or spindle-shaped form. The branches more frequently 
than the main trunk suffer from atheromatous changes, which 
is readily explained from the fact that disease of the surround- 
ing tissue, as in phthisis, not only robs the vessels of their sup- 
port, but more or less interferes with their nutrition, hence 
creates a tendency to degeneration. Rupture of these small 
aneurismal tumors is in many cases responsible for the more 
alarming haemorrhages of phthisical patients. The symptoms 
closely resemble those of aneurism of the aorta, but there is in 
addition more profound disturbance of the pulmonary circula- 
tion, with marked lividity and dyspnoea, cough, expectoration 
and weakness of the right heart. The tumors rarely are large, 
but have a dangerous tendency to rupture into the pericar- 



ANEURISM OF THE CORONARY ARTERIES. 1143 

dium, causing immediate death. The prognosis is bad. The 
treatment is that of aortic aneurism. 



ANEURISM OF THE CORONARY ARTERIES. 

An exceedingly rare condition, and almost always latent. 
The aneurism al sac is small, rarely larger than a small nut, but 
more than one may occupy the same vessel. Rupture occurs 
into the pericardium or the wall of the heart, from erosion. 

ANEURISM OF THE ABDOMINAL AORTA AND ITS 
BRANCHES. 

Aneurism of the abdominal aorta is rare as compared with 
thoracic aneurism. It is oftenest seen in men of from thirty- 
five to fifty years of age. It usually occurs near the ccelic axis, 
especially near the root; it is generally sacculated or fusiform, 
and may be multiple. 

The symptoms consist of sharp, shooting pains, often in the 
epigastric region, resembling gastralgia, frequently following 
the lumbar or sciatic nerve, occasionally localized in the back. 
Gastric symptoms, especially vomiting, may be severe; pressure 
upon the colon may give rise to intestinal disturbance. There 
is colic in case embolism of the mesenteric artery exists. Jaun- 
dice may be present. Retardation and weakness of the 
femoral, as compared with the radial, pulse is common. The 
tumor may project forward in the middle line or to the left of 
the median line or backward, pressing upon the spinal column, 
eroding the vertebrae, and eventually, by compression of the 
cord, give rise to paraplegia. Erosion of the vertebras is ac- 
companied by dull, gnawing pain. A large tumor may lie be- 
neath the diaphragm and escape attention.— Inspection may 
demonstrate the existence of a large tumor, with heaving, for- 
cible, expansible pulsation. — Palpation. The tumor may be 
felt. Dulness on percussion, usually not very pronounced, may 
be distinguished, losing itself in the left lobe of the liver.— Ascul- 
tation. Systolic murmur, more often at the back. Soft, whir- 
ring murmur. Rarely soft diastolic murmur. 

The diagnosis depends upon ability to grasp a large, definite 
tumor — which exceptionally may be freely movable, with large, 



1144 DISEASES OF THE ORGANS OF CIRCULATION. 

heaving, expansible pulsations — and upon the existence of pres- 
sure S3 r mptoms. These distinguish aneurism from the throb- 
bing aorta found in neurasthenia and hysteria, especially of 
anaemic women. 

The prognosis is bad. Exceptionally a spontaneous cure may 
take place, but the tendency is to death from rupture into the 
pleura, retro-peritoneal tissues, stomach, peritoneum, intestine, 
bladder, or spinal canal, rarely externally. Death may also re- 
sult from complete obliteration of the lumen by clotting or in- 
testinal infarction arising from embolism of the superior mesen- 
teric artery. 

The treatment is that of thoracic aneurism. Long continued 
pressure upon the tumor, under chloroform, has been tried in 
appropriate cases, but the results have been unsatisfactory. 

Aneurism of the splenic artery is rare. In a case related by 
Osier the symptoms were: Severe epigastric pain, vomiting, 
haemorrhage from the stomach and from the bowels. Aneurism 
of the hepatic artery is very rare and the symptoms exceedingly 
indefinite. Aneurism of the superior mesenteric artery is very 
rare, and can hardly be recognized. Aneurism of the renal 
artery is less rare; the tumor usually is small; rupture gives 
rise to extensive retro-peritoneal haemorrhage. 

STENOSIS OF THE AORTA. 

Narrowing of the aorta may be congenital. It is usually 
seen in women who all through life were chlorotic, backward, 
and had imperfectly developed genitals. Palpitation of the 
heart, faintness and haemorrhagic tendency are common in such 
cases. The heart is almost always abnormal, either small, di- 
lated or hypertrophied ; valvular disease is common. The con- 
dition may only be suspected, but cannot be distinctly recog- 
nized, during life. A localized narrowing* of the aorta may 
exist near the insertion of the ductus arteriosus, and dates back 
to the period immediately following birth. It is associated 
with other abnormalities of the heart. If not great, it may be 
corrected by secondary hypertrophy of the left ventricle and 
the establishment of collateral circulation. In such cases per- 
sons may live to advanced age. More often, however, the cir- 
culation eventually becomes embarrassed and death results 
from dropsy. Exceptionally stenosis of the aorta results from 



RUPTURE OF THE AORTA. 1145 

enlargement of mediastinal glands or syphilitic infiltration of 
the wall of the aorta. 



RUPTURE OF THE AORTA. 

Rupture of the aorta, save when directly due to a wound, as 
a stab with a knife, rarely occurs in a previously healthy vessel. 
It is almost always associated "with arterio-sclerosis ; in the ab- 
sence of atheroma, a congenital weakness at some point along 
the wall of the vessel will explain the occurrence of the acci- 
dent. There may be special exciting causes, as violent straining 
when at stool or making some special effort, a blow on the 
chest, a fall, etc.; if the artery is diseased, no immediate excit- 
ing cause may appear. The symptoms at the time of rupture 
usually are : agonizing, sudden pain, with a feeling as though 
some vital part had burst, with sensation of impending death, 
followed by fatal collapse. If the intima and media alone are 
torn (dissecting aneurism) the accident is not immediately 
fatal ; a considerable length of time may elapse before the rup- 
ture of the adventitia takes place. 



DISEASES OF VEINS. 

PHLEBITIS. 

An inflammation of the coats of a vein, associated with 
changes in the blood passing through the inflamed spot, arising 
either from a thrombus (endo-phlebitis or thrombo-phlebitis) or 
from primary involvement of the wall of the vessel from exten- 
sion of inflammation of adjacent structures (periphlebitis); the 
former is the more common. 

^Etiology.— Endo-phlebitis practically depends upon the for- 
mation of a thrombus ; hence, sluggishness of the flow of blood 
and abnormal tendency to coagulation of the blood must be 
present. It is common in conditions of greatly lowered vitality 
(phthisis), in septic conditions, and as a complication or sequel 
of acute infectious diseases. One of the best known forms is 
that occurring during the lying-in period of women (phlegma- 
sia alba dolens). Periphlebitis, the form of phlebitis in which 



1146 DISEASES OF THE ORGANS OF CIRCULATION. 

the wall of the vessel is affected first and the thrombosis is sec- 
ondary, may result from traumatism, as in the ligation of a 
vein, but is far more frequently found from extension of a dif- 
fuse cellulitis, after operations, etc., particularly in the presence 
of insanitary surroundings ; it is somewhat allied to phlegmo- 
nous erysipelas. 

Morbid Anatomy.— The pathology of endo-phlebitis depends 
largely upon the fact that coagulated blood, unlike fluid blood, 
attaches itself to the inner coat of the vein, setting up irrita- 
tion, congestion in the vasa vasorum, and injection and thick- 
ening in the sheath and outer and middle coats of the vein, 
eventually resulting in firm adhesion between the wall of the 
vessel and the thrombus. Liquefaction of the thrombus may 
restore the vessel to its normal state, or the adhesion may in- 
crease in firmness and intimacy ,converting it into a fibrous 
cord (obliterative phlebitis) ; or the thrombus may undergo 
calcareous infiltration (phlebolites or vein stones). In periphle- 
bitis the sheath and the outer coat are affected first, from infec- 
tion hy pus contained within the loose connective tissue sur- 
rounding the vessel, and originating either in an open wound, 
or in an ulcer, abscess, or extravasation of blood, or any break- 
ing-down of tissue. The vascularity of the outer coat is greatly 
increased and the wall of the vein much thickened from cellular 
infiltration, so that upon transverse section the walls no longer 
approach each other. The inner coat becomes dull and leaden , 
stained with blood-pigment wherever there is an adhering clot, 
and thickened and roughened, thus affording opportunity for 
the coagulation of the blood-fibrin and the formation of a 
thrombus. The adhesion between the wall of the vessel and the 
thrombus is loose ; thus the entire thrombus may be dislodged 
and carried along into the circulation, with fatal results ; or it 
may be rapidly broken up and smaller portions of it carried into 
the circulation as emboli, producing metastatic abscesses. The 
formation of pus in the walls of the vessel (suppurative phle- 
bitis) is not uncommon; abscess may also be caused by break- 
ing-down of the clot. Often, -when the phlebitis arises from a 
wound, or similar cause, the inflammation extends along the 
sheath of the vein for a considerable distance, the phlebitis oc- 
curring at some point above, presumably determined by the 
looseness of the tissues. 



PHLEBITIS. 1147 

Symptoms.— Pain and tenderness upon pressure is present in 
the greater number of cases, and almost always when a large 
vein is inflamed ; the pain may be intermittent and neuralgic. 
If the affected vessel is superficial, a dusky red line can be traced 
along its course, the vessel itself feeling hard, coral-like and 
somewhat knotted ; usually there is more or less oedema, soft 
and easily pitting upon pressure. If the affected vein lies deep, 
the superficial veins may be painlessly enlarged; swelling is pale, 
hard and tense, and the pain usually greater. The temperature 
is at first somewhat raised ; it falls below normal with the fail- 
ure of circulation. Constitutional symptoms are not often 
pronounced, save when there is embolism, thrombosis or sup- 
puration, in which case symptoms indicative of pyaemia rapidly 
develop. Suppurative phlebitis is most frequently seen in the 
portal vein. 

Diagnosis. — Lymphangitis may closely resemble phlebitis, 
but the inflammation is more diffuse, the redness brighter, and 
there is present adenitis. In erysipelas the redness is more dif- 
fuse, resembling a "blush." 

The prognosis is favorable, save in the suppurative form, 
which is almost surely fatal when occurring in an inner organ. 

Treatment. — Absolute rest of the affected part is of chief im- 
portance. All handling and manipulating of the affected limb 
must be interdicted, since by this means a thrombus may easily 
be dislodged and sent into the circulation with fatal effect. It 
is well to carefully wrap the limb in cotton-wool, secured by a 
few loose spiral turns of a roller bandage, slightly elevate it, 
and hold it in place by sand-bags or splints. Counter-irritation 
by iodine or blisters is worse than useless in the majority of 
cases. Hot fomentations are not only soothing to the patient, 
but infinitely more helpful than counter-irritation. Occasion- 
ally, when there is much congestion, leeching gives good results. 
If abscesses form, they must be opened, with poulticing before 
and after the use of the knife. The treatment of suppurative 
phlebitis is that of pyaemia. 

Therapeutics. — Aconite is of service when there is high and 
characteristic fever; active inflammation. Great dryness, 
thirst, restlessness. — Apis. Transparent, white cedematous 
swelling, with stinging pains in the affected parts. Fever with- 
out thirst; scantiness of urine.— Hamamelis. Soreness and 



1148 DISEASES OF THE ORGANS OF CIRCULATION. 

swelling of the legs, often extending clear up to the trunk. 
Veins hard and swollen, knotty. Often gives excellent results 
when applied locally in hot water, preferably as a strong solu- 
tion of the distilled extract. — Pulsatilla is exceedingly useful 
when the swelling is pale. Characteristic mental symptoms. 
In lying-in women. Shivering, but wants air. Suppression of 
lochia and milk. — Lachesis. Bluish, mottled appearance of the 
parts. In lying-in women. Excessive sensitiveness to the 
touch. Low state of vitality. Suppurative phlebitis of the 
portal vein. 

If there is suppuration, consult Hepar sulph., Silica, Ar- 
senicum. 

DILATATION OF THE VEINS. 

This condition, also called phlebectasis, varix", varicose veins, 
may occur in am^ part of the body, but is oftenest seen in the 
legs and in the plexuses about the rectum and spermatic cord. 
It is more frequent in women than in men and in the old than 
in young persons. 

Its aetiology consists chiefly of conditions which interfere 
with the free passage of blood through the veins; hence among 
its causes we find cardiac affections characterized by weak im- 
pulse of the heart, obstruction in the arteries, cirrhosis of the 
liver, etc.; among those acting more directly, mention may be 
made of the pressure of a gravid uterus or of a rectum filled 
with faecal matter, or the constant pressure upon the veins of 
the lower leg from following an occupation which necessitates 
standing a great deal, especially leaning forward ; a tight gar- 
ter or a truss ma} r produce the same effect. It is probable that 
in advanced age the vessels themselves from weakness show a 
special predisposition to dilatation. 

Morbid Anatomy. — A simple dilatation of the vessel, caused 
by pressure within, is followed by hypertrophy of the muscle- 
cells in the middle coat and hyperplasia of the connective tissue 
in all the coats. The vessel thus increases in thickness and 
length, assuming a tortuous appearance, wavy in outline and 
irregular in calibre. The valves also hypertrophy, but after a 
time are rendered ineffective from the progressive dilatation of 
the vessel, and shrink into useless fibrinous bands behind whose 



DILATATION OF THE VEINS. 1149 

folds blood is retained and coagulates, forming a thrombus. In 
the course of time the surrounding tissue thickens, eventually 
to encroach upon the vein and strangle it. If the vessels of the 
skin overlying a varicosis are destroyed, an ulcer results. A 
vein may approach the surface by pressure thinning the overly- 
ing tissues; its own walls are also thinned and ruptured, re- 
sulting in haemorrhage that may prove fatal. 

Symptoms. — These are unmistakable if, as is usually the 
case, the vessel can be examined by the eye and touch. The 
constitutional symptoms consist of dull, aching pain in the 
parts, with a sense of painful fulness and distension, often with 
great soreness, much increased by walking or standing. A hard, 
resisting oedema of adjacent parts may be present. The stasis 
of the blood often gives rise to eczema and indolent ulceration. 
Varicosis of the hemorrhoidal veins may be accompanied with 
intense inflammation. 

Treatment. — Whenever the cause can be reached, it must be 
done promptly. If the varicosis is in the leg, an elastic band- 
age should be applied, and rest maintained in the recumbent 
position and with the leg slightly elevated. Very often surgi- 
cal means alone are efficient, bringing about obliteration of the 
vessel. 

The remedies upon which most dependence can be placed are 
Hamamelis, Belladonna, Pulsatilla, Nux vomica, Sulphur. 
Remedies may be very useful in reaching the primary cause ; 
thus, remedies acting upon the liver often are most efficient in 
curing varicosis depending upon hepatic disease ; in the same 
way Digitalis, Cactus, Strychnia, and other cardiac stimu- 
lants, may afford relief when the first cause lies in a weak 
heart ; and Nux, ^Bsculus, Collinsonia and Lycopodium are 
often of greater value in the treatment of varicosis of the 
plexus of veins about the rectum than recent and at the present 
very popular surgical methods. A close study of the materia 
medica here very often excels in radically curative effects the 
knife of the surgeon. 



PART IX. 

DISEASES OF THE BLOOD AND 
DUCTLESS GLANDS. 



PART IX. 



Diseases of the Blood and Ductless 
Glands. 



ANAEMIA. 



The term anaemia covers a diminution of the amount of blood 
in the body or a diminution of some of its important constitu- 
ents, chiefly haemoglobin and albumin, involving a deteriora- 
tion in quality. The condition, as here considered, may be pri- 
mary or secondary ; of these the secondary form is by far the 
more common, and will be considered first. 

SECONDARY AlV^MIA. 

Secondary anaemia is the result of abnormal processes usually 
found under one of the following : Haemorrhage, which may be 
spontaneous or follow some injury. If large and rapid, it fre- 
quently proves fatal, not so much from the great amount of 
blood lost, as from the rapid lowering of arterial tension. A 
very rapid haemorrhage with the loss of only a few pounds of 
blood may prove fatal, while slow bleeding, involving the loss 
of a much greater amount of blood, may not prove equally se- 
rious. The effect of small, but frequently repeated, bleeding — 
as in purpura, uterine cancer, etc. — may give rise to rapidly fa- 
tal anaemia, as may also a single severe haemorrhage. The very 
young and the old cannot endure as great a loss of blood as 
persons in the prime of life. It is estimated that the loss of one- 
third of the whole amount of blood is necessarily fatal. The 
process of regeneration is rapid. Watery and saline constitu- 
73 



1154 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

ents are easily replenished from the gastro-intestinal tract ; the 
blood corpuscles are restored rapidly, haemoglobin somewhat 
more slowly. Inanition, the result of deficient supply of food 
or of some condition, like stenosis of the oesophagus or chronic 
dyspepsia, which interferes with digestion and assimilation. 
In these cases the blood plasma suffers most. A heavy drain 
on the albuminous materials of the blood, as occurs in pro. 
longed lactation, Bright's disease, chronic suppuration, etc. 
Poisoning- by mercury, arsenic, lead and phosphorus or the 
toxic action of the specific organisms of malaria, syphilis, tu- 
berculosis, etc. The red corpuscles here are destroyed or their 
consumption greatly increased. 

The symptoms of acute anaemia, such as results from severe 
bleeding, are pallor, cyanosis, collapse, with cold and clammy 
skin, weak and fluttering action of the heart, dizziness, ringing 
in the ears, faintness, dyspnoea, anxiety about the heart, 
nausea and vomiting, fainting, sometimes convulsions, and pro- 
longed loss of consciousness. Chronic anaemia is characterized 
chief!}' by a cachectic state, with gray or greenish-gray appear- 
ance of the face, emaciation, weak and irritable heart, relative 
valvular insufficiency, anaemic murmurs heard over the vessels, 
especially at the root of the neck. Later, oedema, first about 
the ankles, in the serous sacs, albuminuria, bronchial catarrh, 
pulmonary oedema; all these are associated -with dyspepsia, 
menstrual disturbances (amenorrhoea), sleeplessness, mental 
and nervous disorders. 

The treatment consists of removal of the cause, rest and gen- 
erous diet. The administration of iron in some form (chaly- 
beate waters, tartrate of iron and potassium, officinal tincture 
of perchloride of iron, Bland's pills) is universally recom- 
mended. Light doses of the tincture of Cinchona in water, fre- 
quently administered, is an exceedingly useful remedy in over- 
coming the effects of a severe haemorrhage. Other remedies will 
be considered in subsequent chapters. 

PRIMARY OR ESSENTIAL AN£I«IA. 

CHLOROSIS. 

An affection characterized by a deficiency of haemoglobin in 
the blood, without a corresponding diminution of corpuscles, 
with constitutional symptoms of chronic anaemia. 



PRIMARY OR ESSENTIAL ANAEMIA. 1155 

Etiology. — Chlorosis occurs so frequently in young women 
at the age of puberty that it is almost considered a disease pe- 
culiar to young girlhood. Cases are, however, recorded in 
which the affection appeared in -women who had long passed 
this period of life, as late as the forty-fifth year, and in young 
men at the age of puberty. The disease seems to have a prefer- 
ence for delicate blondes. The patient may show the pallor of 
chlorosis for a considerable period prior to the appearance of 
menstruation, which proves tardy and scanty, with a fixed 
tendency to amenorrhcea. Heredity is distinctly recognized in 
many cases, and some writers assume that it occurs with more 
than usual frequency in those of tubercular tendency. 

The essential nature of chlorosis is not understood. By some 
it is thought to be primarily a disease of the blood. Virchow 
considers it a congenital hyperplasia of the vascular system. 
Many believe that it is of nervous origin, and in defence of this 
position cite its • occurrence after violent emotions, homesick- 
ness, jealousy, or disappointment in love. Masturbation and 
other sexual vices has been thought the chief factor, but there 
is no conclusive evidence to sustain the assertion. Sir Andrew 
Clark is inclined to consider it the result of auto-intoxication, 
putrefactive matter being absorbed from the colon ; Pick ad- 
mits that the absorption of such products into the system is 
the responsible factor, but claims that they are obtained from 
a dilated stomach. This great divergence of opinions shows 
how little is really known of the aetiology of the affection. It 
appears as though an inherited dyscrasia of the blood might be 
an important factor, readily assuming a serious aspect under 
conditions which lower the tt>ne of the system and lessen its 
powers of resistance. Thus whatever depresses the nervous 
system, be it a severe disappointment, sexual vice or violent 
disturbances in the emotional sphere, would have important 
bearing upon the case. In the same manner we can largely ac- 
count for the fact that, as a rule, chlorosis seeks its victims 
among young girls who either have grown up amid unfavora- 
ble, insanitary surroundings or who by close confinement to 
some steady in-door occupation, as sewing or working in badly 
ventilated factories, have been deprived of the fresh air, sun- 
shine and abundance of good nourishing food which the period 
of adolescence imperatively demands. 



1156 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

Symptoms. — Chlorosis may be a transient condition, passing 
away after a few weeks or months, possibly recurring, or it 
runs a steady course of considerable duration. The onset may 
be sudden ; oftener it is gradual. A sense of slowly increasing 
weakness is noticed, with an inclination to sleep long and 
often, both day and night. There is pallor of the face, head- 
ache, dizziness, blurred vision, easy fatigue and embarrassment 
of breathing from slight exertion, palpitation of the heart, de- 
layed and scanty menstruation, at times well defined amenor- 
rhoea. It is the occurrence of menstrual trouble, with the "run- 
down" state of the system, which usually first brings the pa- 
tient to the physician. Her appearance then is that of chronic 
anaemia, with some oedema about the eyes and ankles ; there is 
evidence of insufficient oxygenating power of the blood in the 
easily excited dyspnoea, tendency to fainting and palpitation 
of the heart, with a rather rapid, excited pulse and a consider- 
able increase of the respiration both when awake and during 
sleep. The mucous membrane of the mouth and tongue looks 
pale, and the skin is of a greenish-yellow tinge (green-sickness), 
which is diagnostic. Exceptionally the dilated blood vessels of 
the cheeks show plainly and give to them a flushed appearance 
(chlorosis rubra). The body is almost always well nourished. 
The appetite is poor and perverted, the patient having a strong 
craving for sweets, pickles, chalk, slate pencils or other indiges- 
tible substances. Eructations and regurgitation of food, espe- 
cially in the morning, is common, and in many cases there is 
severe gastralgia. The digestive symptoms, on account of 
their severity and the constancy of their occurrence, have been 
carefully studied ; the existence of an excess of free hydro- 
chloric acid has been demonstrated by Oswald ; there is usually 
a decided lack of motor activity, and dilatation of the stomach 
is often present. It is on this account that several European 
authorities of eminence strongly advocate lavage of the stom- 
ach in the treatment of chlorosis, and claim for it good results. 
The bowels are constipated in a majority of cases. Derange- 
ments of the menstrual function naturally become the object of 
special concern to the patient ; amenorrhoea is the rule ; excep- 
tionally menorrhagia has been observed. With this general de- 
cline of health the nervous system suffers, and headache, 
usually vertical, nervous irritability, hysterical manifestations 



PRIMARY OR ESSENTIAL ANAEMIA. 1157 

and neuralgia are common. Fever is not often present, but a 
"febrile chlorosis" is described in which there is daily eleva- 
tion of the temperature. The urine is normal; sometimes, espe- 
cially when there is a decided hysterical tendency, it is pale, oc- 
casionally slightly alkaline, with a specific gravity of about 
1.015. The heart may be slightly enlarged ; severe palpitation 
is common; murmurs are frequent; there is a systolic souffle at 
the base, usually in the pulmonary region ; accentuation of the 
second sound of the pulmonary valve is often heard ; venous 
hum or "bruit de diable" is easily perceived in the right internal 
jugular vein. 

Examination of the blood shows that in all severe cases, and 
usually in light cases, there is a diminution of the red globules 
(oligocythemia), but that the essential feature is a great di- 
minution of the haemoglobin, of which not more than 35 or 40 
per cent, may be present. This is easily recognized by the 
striking pallor of the corpuscles when a drop of fresh blood is 
examined under the microscope. Poikilocytosis is rare ; some- 
times nucleated cells may be seen. 

Gastric ulcer, transitory nephritis, and venous thrombosis 
are frequent complications. The latter occurs oftenest in the 
femoral and brachial veins, and is then comparatively harm- 
less ; occasionally there is thrombosis of the longitudinal sinus, 
with, sometimes, fatal results. 

Diagnosis. — The diagnosis rarely presents much difficulty ; 
but it is necessary to exclude tubercular disease of the lungs in 
its early stage, and organic disease of the heart and kidneys. 
It is evident that a carefully made microscopic examination of 
the blood is almost indispensable to a positive diagnosis. The 
absence of causes of a secondary anaemia must also be carefully 
considered. The clinical history of the case and the course of 
the symptoms is of importance, since in advanced cases of chlo- 
rosis there may be a great diminution of the number of red 
blood corpuscles as well as a lowering of the percentage of 
haemoglobin. 

The prognosis is favorable. Relapses occur when treatment 
is discontinued too soon, often from pregnancy, and at times 
without apparent cause ; it is said that a special tendency to 
recurrence of the affection exists in the third decade of life. The 
disease may prove fatal from ulceration of the stomach, venous 



1158 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

thrombosis, or from congenital anomaly of the genital or vas- 
cular systems. 

Treatment. — In all cases, light or severe, efforts must be 
made to regenerate the blood by appropriate changes in the 
surroundings, habits, and diet of the patient ; to such measures 
the patient often responds with surprising promptness. The 
tendency to relapse is, however, so great that it is wise to in- 
form the patient on the start of the necessity of prolonging 
treatment, regardless of any improvement in the symptoms 
until the blood has fully regained its normal condition. A' 
change of some sort in surroundings is almost always advisa- 
ble, from the city to the country, from the mountains to the sea- 
shore, from the sea-level to the hills. The change made, the pa- 
tient must be directed to spend in the open air such time as she 
is not resting. There is great need of abundant rest, and often 
mischief is done by encouraging an amount of exercise which 
exhausts the patient. It is always best, even in light cases, to 
positively prohibit exercise to the extent of becoming fatigued, 
and in severe cases absolute rest in bed, with systematic and 
generous feeding, as practised in some forms of neurasthenia, is 
indispensable. The diet is to be carefully regulated. It must 
be nutritious and easily digested. It should be rich in albumin. 
Milk is good, but not as an exclusive diet. Carbohydrates and 
fats are of advantage when the patient is thin and lean. Alco- 
holic stimulants should be excluded, but beer and heavy porter 
may prove grateful and increase the desire for food. Hot salt- 
water baths may be taken two or three times each week, not to 
exceed fifteen minutes in duration. Often the momentary hot 
douche, followed by a momentary cold douche, is very valuable. 
Some practitioners claim to have derived benefit from the cold 
pack ; its usefulness depends upon the patient's power to react 
promptly. Particular care must be taken when there are symp- 
toms of approaching menstrual flow. The patient must then 
be given hot hip baths and kept in bed until the flow has 
ceased; hot drinks (ginger, etc.) are useful at this time. Con- 
stipation should be managed by the free use of fruits and of 
appropriate food, as Graham bread. Laxatives are not satis- 
factory. The use of some form of iron (Bland's pills, two five- 
grain pills after each meal ; chalybeate waters ; Gude's pepto- 
mangan) is still the favorite prescription with the great body 



PRIMARY OR ESSENTIAL ANAEMIA. 1159 

of practitioners. Arsenic (two drops of Fowler's solution after 
each meal) is often serviceable ; hydrochloric acid (ten to fifteen 
drops in a wine-glassful of -water) relieves many of the distress- 
ing gastric symptoms ; lavage of the stomach is warmly advo- 
cated by some authorities ; Strychnine and other powerful 
tonics are occasionally helpful. 

Therapeutics. — Of the long list of remedies which suggests it- 
self here, Ferrum, Calcarea, Pulsatilla and Natrum muri- 
aticum are the most frequently indicated and useful. Ferrum 
has great prostration and muscular weakness, so that the 
patient quickly tires from even a slight exertion ; restlessness ; 
she cannot keep quiet, and although perfectly exhausted from 
moving about, feels that she must keep on the move. With this 
restlessness there is great sensitiveness to pain of any kind. 
Chilliness during a great portion of the day, with feverish 
flushing at night. Despondency; hypochondriasis; melancholia. 
Pallor of the face and of the mucous membranes ; yet, the face 
flushes easily from the slightest exertion or mental excitement. 
Vertigo, with flushing of the face, from stooping forward. or 
riding in a car, or from making a motion, with ringing in the 
ears. Violent headache, worse from motion, with flushed face, 
cold hands and feet, and weak, soft pulse. Oppression in the 
chest, dyspnoea, rapid action of- the heart ; palpitation. An- 
orexia; dislikes the very food her condition demands; op- 
pressive, cramp-like pain after eating ; gastralgia. The menses 
are pale, acrid, watery, followed by milky, acrid leucorrhcea. — 
Calcarea carbonica. It profoundly affects the general nutri- 
tion. Acts best in those of fair complexion, fat, weak, slow of 
action and motion, who perspire easily and profusely, and 
whose extremities are habitually cold. The disposition is anx- 
ious, brooding and fretful; fusses about, but accomplishes 
nothing, yet is greatly prostrated, as though she had done a 
great deal. Is tired particularly from climbing up-stairs or 
going up even a slight ascent. Palpitation of the heart, 
brought on often by brooding over the dreadful things she fan- 
cies are going to happen. Congestive headaches and chronic 
headaches with pale face and cold feet. Indigestion. Intense 
craving for indigestible substances, hard boiled eggs, chalk, etc. 
Everything eaten turns sour ; sour eructations ; bloated abdo- 
men. Amenorrhoea of young girls, with headaches (Calc. phos. 



1160 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

in anaemic young school-girls, with constant headache on top 
of head, d3 r spncea from going up-stairs), congestion to the 
head, profuse, milky leucorrhcea. — Pulsatilla. In girls of 
mild, yielding disposition, who fancy themselves overburdened 
with care, and thus grow despondent. Weakness, with disin- 
clination to exertion. Feels tired and lazy ; wants to sleep all 
the while, not only late in the morning, but for hours during the 
day; if she, after considerable persuasion, is induced to take a 
short walk, comes home tired and wants to lie down and sleep. 
Feels chilly, with burning heat at night, without thirst ; long- 
ing for fresh air; palpitation. Headache, chiefly in the fore- 
head, worse in the room and from trying to think ; better in 
the open air. Vertigo, particularly from looking up, with 
nausea and indigestion. Indigestion ; digestion is exceedingly 
slow ; tongue heavily furred, taste bitter, appetite gone ; chilli- 
ness ; all the symptoms worse from eating. Craves acids. Gas- 
tralgia. Regurgitation of food. Menstruation is delayed ; men- 
strual headaches ; pudenda hot and swollen; thick, bland leucor- 
rhoea. — Natrum muriaticum. Depression of spirits, great sad- 
ness, she is disheartened and wants to be left to herself ; or irri- 
tability and ill humor. Periods of depression, accompanied 
with palpitation and sense of coldness about the heart ; 
awakens in the morning sad and depressed, with headache, 
patchy tongue, palpitation, etc. Severe headache, usually 
frontal, with dizziness ; vertigo, with tendency to fall forward 
and to the left. Stubborn constipation, with sense of constric- 
tion at the anus and difficult expulsion of the stool ; dry, hard 
stools. Delayed menstruation, dysmenorrhcea, menstrual 
headache, with weakness, abdominal soreness, thirst, dryness 
of the mouth ; back aches as though broken ; feels better when 
lying on the back, on a pillow. Circulation is easily excited ; 
any exertion, even though slight, causes throbbing all over the 
body. 

Other remedies frequently indicated are: Cyclamen. Resem- 
bles Pulsatilla in the mental sphere, and differs from it in its 
absolute dread of fresh air. One-sided headaches, anaemic in 
origin, with much debility, in girls suffering from menstrual de- 
rangements. Indigestion, with dislike of fat. Chlorosis with 
scanty and suppressed menstruation ; chilliness, gastric discom- 
fort, etc. — Graphites. In large, fleshy persons, with tendency 



PROGRESSIVE PERNICIOUS ANAEMIA. 1161 

to herpetic eruptions. Flushing of the face (Ferrum), rush of 
blood to the head; menses scanty, delayed, pale; profuse leuc- 
orrhcea ; constipation ; face pale, yellowish ; oedema of eyelids 
and external genitalia ; gastralgia some hours after eating, 
worse from cold drinks. — Phosphorus. In thin, narrow- 
chested persons, with tubercular tendency. Mental and phys- 
ical exhaustion; "leucorrhcea of a whitish, watery slime, espe- 
cially profuse during the time of the menses, sometimes acrid 
and corroding." Gastric ulcer. In very tedious chronic cases. — 
If constipation is a prominent symptom, consult also : Alum- 
ina, Antimonium crudum (great indisposition to physical exer- 
tion; irregular stool), Bryonia, Nux vomica, Plumbum, Sul- 
phur. If there are marked disturbances of the sexual function, 
consult Helonias, Sabina, Sepia. Cuprum is said to act well 
after the abuse of iron ; worse during hot weather. 

PROGRESSIVE PERNICIOUS ANEMIA. 

This form of anaemia, first described by Addison, and known 
also as "idiopathic" and "essential" anaemia, is characterized 
by an enormous diminution of red blood-corpuscles with rela- 
tively less striking diminution of haemoglobin. Absolutely noth- 
ing is known of its causation. Cases of fatal secondary 
anaemia due to such causes as haemorrhage from disease or in- 
jury or to the presence of animal parasites in the intestine (as 
the anchylostomum duodenale or the filaria sanguinis hominis) 
are excluded from consideration here. The disease is not re- 
stricted to any geographical limit, occurs oftener in the middle- 
aged, rarely in the young, is rather more frequent in women 
than in men, and, it is thought, has some connection, serolog- 
ically, with pregnancy, parturition, and mental shock. Three 
cases, recently observed, occurred in women who had just 
passed the climacteric period ; two of these had excellent ante- 
cedents as to health and mode of living, and were of a de- 
cidedly nervous temperament and of energetic habit. 

Morbid Anatomy. — The most striking feature is the pallor of 
the bodily surface, mucous membrane and organs, the skin par- 
taking of a tinge of light lemon-yellow. The body usually is 
well nourished, and there is a full normal amount of adipose 
tissue. Fatty degeneration of the heart, kidneys and liver, espe- 



1162 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

dally of the heart, is common and frequently extensive ; the 
intima of the small vessels may also show fatty degeneration. 
It is not unusual to see minute haemorrhages in the organs, 
mucous and serous membranes, and occasionally in the skin. 
The yellow marrow is diminished in amount ; the marrow ap- 
pears red and contains many red blood corpuscles ; i. e. normo- 
blastic red marrow. "In a case reported by Rindfleish the mar- 
row appeared to be one large mass of nucleated red cells, and 
Rindfleish is inclined to think that the cause of pernicious 
anaemia was an inability of the organism to change the nucle- 
ated red cells into the normal non-nucleated red blood corpus- 
cles" (Osier). 

Symptoms.— Usually the disease develops with such insid- 
iousness that it is impossible to fix the exact time of its begin- 
ning. The patient tires from slight exertion, is short-breathed 
and experiences some palpitation of the heart; pallor of the 
lips, tongue, and skin attracts attention, but often is treated 
lightly because there is no loss of flesh and the constitutional 
symptoms are not severe. Later there may be more or less 
headache, in some cases with ringing in the ears and vertigo, 
and the skin gradually assumes the light lemon-3 r ellow tint. 
The appetite is variable, usually poor; there may be nausea, 
vomiting and diarrhoea. Thirst and great fetor of the breath 
are common. Less often the appetite is good, even craving, and 
in such cases constipation is the rule. Epigastric tenderness is 
almost always present. The liver is normal or slightly en- 
larged ; the spleen may present an increased area of dulness. 
The patient now complains more and more of increasing de- 
bility, and is content to spend a great portion of her time in 
bed. There is dyspnoea, which in some instances occurs early, 
and frequently becomes a source of great suffering ; eventually 
there may be pulmonary oedema and dropsy. The urine shows 
an increase of urea and uric acid, is dark, of low specific grav- 
ity, and under the spectroscope shows pathological urobilin. 
There may be no fever, but in the greater number of cases there 
are irregular, remittent periods during which the temperature 
is elevated, sometimes quite high. More or less complaint is 
usually made of a sense of fulness about the heart or, in others, 
of a sense of great cardiac weakness. Physical examination 
shows a loud venous hum in the neck, with various murmurs 



PROGRESSIVE PERNICIOUS ANEMIA. 1163 

in the region of the heart, visible throbbing in the large arte- 
ries, and sometimes capillary pulse. GBdema of the ankle be- 
comes pronounced ; the weakness increases ; hemorrhagic effu- 
sions into the skin and mucous membrane are observed ; more 
rarely retinal haemorrhage occurs, with narrowing of the field 
of vision and blindness ; the mind wanders, and the patient 
gradually falls into a state of extreme prostration, terminat- 
ing in death. 

In some cases the nervous system especially suffers from the 
anaemic state, presenting symptoms which closely resemble 
neurasthenia. There is insomnia, occasionally alternating with 
sopor, sensory disturbances, "band-like" sensations, strange 
discomfort in the head, rarely amounting to severe pain, but 
associated with confusion of ideas and slow, hesitating, even 
incorrect, speech, numbness and tingling in the hands and feet, 
with paralytic weakness in the extremities. Unless the anaemia 
has progressed far, this rarely occurring, yet distinct, form may 
become a source of some perplexity in rendering an immediate 
diagnosis. 

An examination of the blood shows it thin, pale, amber-like ; 
exceptionally it is dark and deficient in iron. Oligocythaemia is 
always very pronounced, but the loss in haemoglobin is not as 
great as that of red blood corpuscles, a point of importance in 
differentiating between progressive anaemia and chlorosis or 
secondary anaemia. Under the microscope one-fourth, or more, 
of the blood corpuscles appear very large (macrocytes), while 
others are below the normal in size (microcytes), and a very 
large percentage of them is misshapen (poikilocytic). The 
number of leucocytes is normal or slightly below normal. A 
striking feature is the absence of the "rouleaux" in which the 
red corpuscles naturally arrange themselves ; here they are ir- 
regularly scattered over the entire field. 

Diagnosis. — The differentiation of progressive anaemia from 
chlorosis or secondary anaemia rests upon the progressive nature 
of the disease, the lemon-yellow color of the skin, the inability 
to find an immediate cause for the occurrence of the disease, the 
presence of haemorrhagic effusions, especially into the retina, 
and the result of careful examination of the blood, with par- 
ticular attention to the relative proportion of the red corpus- 
cles and haemoglobin. 



1164 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

The prognosis is very serious. Death usually occurs in one or 
two years, in the majority of cases from exhaustion or maras- 
mus. 

Treatment. — Rest in bed and careful attention to diet are ex- 
ceedingly important. It is not good practice to send such cases 
far from home; the}', more than almost am' other class of pa- 
tients, require the comforts which a well regulated home alone 
can give, and must most closely economize their strength. The 
diet should be nourishing and not tax the digestive powers. 
Massage frequently is of great service. Iron has proved wholly 
disappointing. Arsenic (arsenious acid; Fowler's Solution) is 
the only remedy credited with cures in a small number of cases. 
Two drops of Fowler's solution should be given three times a 
day, after each meal, and increased slightly every few days, per- 
haps every week. It is usually well borne, but must be discon- 
tinued if it disturbs the digestion or the urine becomes albu- 
minous. The drug should not be discontinued because of slight 
puffing of the face unless the urine contains albumin. There is 
no proof that transfusion of blood has yielded permanent good 
results, and the operation itself is not free from danger. Of 
late the bone-marrow treatment has found a few warm advo- 
cates, but the evidence in its favor is not conclusive. The raw 
red marrow from calves or other young animals may be given 
in glycerine, extract or capsule. Feeding by the oesophageal 
tube may become necessary. The long-continued use of Gudes 
pepto-mangan appears occasionally to benefit the patient. 
Clinicians of the homoeopathic school have added little to the 
therapeutics of the disease. The\% also, have found in Arsenic 
the remedy which accomplishes most, usually giving it in the 
form of low triturations of arsenious acid, when symptomati- 
cally indicated. Phosphorus, Picric acid and Iodine (Arseni- 
cum iodatum) should be carefully studied. 

LHIK.KMIA. 

An affection characterized by a remarkable and persistent in- 
crease of white corpuscles. It is associated with changes either 
in the spleen and bone-marrow, the blood showing an increase 
in elements derived from these organs (spleno-medullary leu- 
kgemia), or with changes in the lymphatic glands, the blood 
showing an increase of elements derived from them (lym- 



LEUKEMIA. 1165 

phatic leukaemia). Frequently the form of trie affection is 
mixed. 

Etiology. — The essential cause of leukaemia is unknown. 
The disease usually occurs in middle life, but has been observed 
in the very young and in the aged. Men are its victims oftener 
than women ; if in the latter, pregnancy and the climacteric pe- 
riod appear to be factors. The poor and those living amidst 
insanitary surroundings, and persons who have had serious 
afflictions or mental trouble, seem especially liable to it. In 
other cases leukaemia follows tedious, exhausting diseases, as 
malaria, tuberculosis, syphilis, rickets ; Gowers, in his table of 
150 cases, furnishes thirty cases in which leukaemia followed in- 
termittent fever. In some cases no cause whatever can be found . 
Heredity is beyond doubt a factor of some importance. 

Morbid Anatomy. — The essential feature is an increase of the 
white blood corpuscles, which in a normal state exist in pro- 
portion of 1:300 or 1:400 ; in leukaemia they reach the propor- 
tion of 1:40 to 1:10, and in very severe cases even of 1:3 or 1:2 ; 
exceptionally, 1:1. Hyperplasia of the organs which are inti- 
mately connected with the white corpuscles, i. e., spleen, mar- 
row and lymphatic glands, is in all cases conspicuous. Each 
of these may be affected alone or all may be simultaneously in- 
volved ; usually the spleen and the bone-marrow are affected at 
the same time. 

The enlargement of the spleen is often enormous, the organ 
weighing from three or four to thirteen, and even eighteen, 
pounds, and measuring a foot in length. It is resistant to the 
knife and, when cut, of reddish-brown, later of yellowish, color. 
Adhesions to the diaphragm, stomach or abdominal wall are 
frequent. Microscopically there is "enlargement of the blood 
vessels and a great increase in the cells of the pulp and of the 
follicles. Sometimes the hyperplasia of the follicles predomi- 
nates, giving the spleen a spotted appearance, like marble. In 
such cases the pulp usually presents retrograde metamorphosis, 
with atrophy and fatty degeneration of its cells and deposits 
of pigment. In advanced cases a considerable amount of firm 
connective tissue may be present. There are often haemor- 
rhagic infarctions, presenting the appearance of circumscribed 
spots, dark red, or in the later stages brownish-yellow, in 
color" (Struempell). The bone-marrow undergoes very strik- 



1166 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

ing changes. The fat disappears, and there is an increase of 
the nucleated red blood corpuscles (lymphoid marrow) or there 
is an increase of the large cells with single large nuclei — inyclo- 
C3'tes — which, with the large number of leucocytes gives to the 
marrow a pruriform (pyoid) appearance, like the "core of an 
abscess" (Osier). The enlargement of the lymphatic glands is 
often sufficient to cause actual deformity. It is more percepti- 
ble in the cervical, axillary, mesenteric and inguinal groups. The 
glands may be soft or hard, of varying size and shape, discreet 
or agglutinated. The hyperplasia may involve the lymphatics 
at the base of the tongue, Peyer's patches, the solitary follicles, 
and those of any organ of the body. The liver and kidneys 
may become enlarged from diffuse leuksemic infiltration, and 
the former especially, but the kidneys as well, may be the seat 
of distinct leukemic growths, presumabty the result of an ag- 
gregation of leucoc3 r tes which have left the capillaries. The 
blood is of a pale, pink color ; the clots are soft, of a gra3'ish- 
green, and from the enormous excess of leucocytes closely re- 
semble pus. Its alkalinity^ and specific gravity are lowered, 
while the fibrin is increased. After death, octahedral crystals 
(Charcot's crystals) are found in the blood, spleen, marrow and 
liver. There is much wasting of the body, general dropsy, and 
often traces of internal haemorrhage. 

Symptoms. — The symptoms at first are those of an anaemia: 
pallor of the skin and mucous membrane, headache, ringing in 
the ears, shortness of breath from any exertion, palpitation of 
the heart and anaemic murmurs, slight oedema, visual disturb- 
ances, epistaxis, and progressive loss of strength. The physi- 
cian usually first sees the patient after the spleen has become 
materially enlarged. 

In the spleno-medullary form, which is b} r far the more fre- 
quent form of leukaemia, the gradual and progressive enlarge- 
ment of the spleen constitutes the most striking symptom. It 
extends downward and toward the right, often as low as the 
pubes and considerably beyond the median line. It can easily 
be felt; the inner edge especially is well defined, rather sharp in 
outline, and presents the characteristic notches. There may, 
or ma}' not, be pain and tenderness on pressure. Gastric dis- 
tress after eating and more or less shortness of breath result 
from pressure on the stomach or crowding-up of the dia- 



LEUKEMIA. 1167 

phragm. The size of the organ may be temporarily increased 
after eating a full meal and diminished from an attack of diar- 
rhoea or haemorrhage. Shortness of breath is common, and is 
largely anaemic. Pulmonary oedema is not rare in the latter 
part of the disease, but such complications as pneumonia are 
infrequent. There may be a good deal of nausea, vomiting and 
diarrhoea, and occasionally intestinal haemorrhage ; ascites 
may result from the splenic enlargement. Leukaemic infiltra- 
tion in the peritonaeum may cause peritonitis. The pulse is 
usually soft, compressible, rapid, but rather full. Haemor- 
rhages, particularly from the nose and gums, are frequent. 
QEdema of the feet and anasarca arise from the enfeebled circu- 
lation. Retinitis may result from the presence of small leukae- 
mic deposits or from haemorrhage; deafness may be caused 
from haemorrhage into the auditory nerve, and symptoms re- 
sembling those of Meniere's disease have been described by 
some observers. Fever is present in most cases. It usually oc- 
curs at irregular and prolonged intervals; the temperature rises 
to 102° or 103° ; there may be a chill and profuse, exhausting 
sweating. The urine has a specific gravity of 1.020 to 1.027, 
with increased excretion of nitrogen and, often, of uric acid. 
One of the most striking symptoms observed and as yet unex- 
plained, is the occurrence of intense priapism, sometimes contin- 
ued for a period of weeks. Coma occasionally results from 
cerebral haemorrhage. 

The blood demands especial study. Its pallor and thinness 
are at once noted. The microscope shows the enormous in- 
crease of white blood corpuscles. "The size of the white cor- 
puscles varies in different cases, and also in the same case. Vir- 
chow has called attention to the fact that the smaller cells orig- 
inate mainly in the lymph-glands, and are therefore especially 
numerous where the leukaemia is of a lymphatic type. The 
larger cells are referred mainly to the spleen and marrow. The 
marrow is also said to contribute certain extremely large nu- 
cleated cells, the dimensions of which considerably exceed those 
of the normal white blood corpuscles. It is not always possi- 
ble to determine the origin of the white cells from their size. 
Ehrlich has succeeded in making out various forms of white 
corpuscles by staining. What are called 'eosinophilous cells' 
are especially increased in the blood of leukaemia. These are 



1168 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

colorless cells, the granules of which take a deep stain with 
acid pigments, but not with basic. Coincident with this in- 
crease of white cells in leukaemia there is almost always a con- 
siderable diminution in the number of red blood corpuscles. We 
also find an occasional nucleated red blood corpuscle in leuke- 
mic blood, and sometimes also microcytes, poikilocytes and al- 
most always a large number of 'granule masses' interspersed 
between the blood corpuscles" (Struempell). 

Lymphatic leukaemia is a much rarer form of leukaemia. Its 
symptoms resemble those already described, but the affection 
shows a preference for young persons and runs a more rapidly 
fatal course than the spleno-medullary form. The glandular 
enlargements are usually of moderate size and involve the su- 
perficial groups. There is rareh r much pain or tenderness in 
the affected glands, but they usually cause pressure symptoms, 
as oedema from pressure upon the veins or dyspnoea from pres- 
sure upon the trachea or bronchi. Splenic enlargement is al- 
most always conspicuous. The histological character of the 
blood differs from the spleno-medullary form in that the in- 
crease in the colorless elements is never so great and consists 
almost wholly of lymphocytes. There are few eosinophiles and 
nucleated red corpuscles, and no myelocytes. 

Diagnosis. — The presence of anaemia with enlargement of the 
spleen or of the lymphatic glands is presumptive evidence of 
leukaemia ; but since the clinical history of this affection closely 
resembles Hodgkin's disease and splenic anaemia, microscopic 
examination of the blood alone can render the diagnosis posi- 
tive. It is also necessary to differentiate between leucoc\^tosis 
and leukaemia. "For this purpose the relative proportion of 
red to white corpuscles is of no value except in extreme cases, 
since a proportion of one leucocyte to twenty red corpuscles 
has been found in leucocytosis. In leucocytosis the total num- 
ber of red blood corpuscles is usually relatively normal, in 
leukaemia it is markedly diminished. In leukocytosis, according 
to Ehrlich, there is a disproportionate excess of polynuclear 
leukocytes, which normally constitute three -fourths or two- 
thirds of the total number of leukocytes. It may be impossible 
from the examination of the blood alone to make a diagnosis 
of leukaemia in its early stage or when myelocytes are absent. 
The characteristics of the blood mav van' from time to time. 



PSEUDO-LEUKEMIA. 1169 

A predominance of the large mononuclear forms is suggestive 
of a conspicuous affection of the spleen, while an excess of the 
small mononuclear forms indicates an affection of the lym- 
phatic glands, and abundant myelocytes — myelaemia — if occur- 
ring, would indicate a conspicuous medullary or myelogenous 
leukaemia. According to Fraenkel, the blood of acute leukaemia 
is distinguished from that of chronic leukaemia by a prepond- 
erance of large and small mononuclear leukocytes and an ex- 
cessive diminution of the polynuclear variety. In chronic 
leukaemia there is an increase of all varieties in addition to the 
presence of myelocytes. The existence of changes in the bone- 
marrow is favored by conspicuous tenderness of the bones, al- 
though Litten denies the diagnostic importance of this symp- 
tom" (Wood and Fitz). 

Prognosis. — The disease is usually seen in the chronic form 
and then terminates fatally, in the great majority of cases, 
within two, or at most three, years. Exceptions are to be 
noted, for occasional recoveries are claimed ; again, the dura- 
tion may exceed the limit of time given. Periods of temporary 
improvement are not unusual. Acute cases of the lymphatic 
form often run a rapid course, death occurring in a few weeks. 
In the chronic type the duration largely depends upon freedom 
from complications, absence of high fever, haemorrhages, ex- 
hausting diarrhoea and dropsy. Death is likely to result from 
progressive exhaustion, often hastened by pulmonary oedema. 
Pneumonia developing, a rapidly fatal termination is quite 
sure. 

Treatment. — So far, all treatment employed has proved 
futile. The general plan outlined under progressive anaemia, 
unsatisfactory as it is, must be followed. The persistent use of 
Arsenic promises most. All operative measures so far sug- 
gested are worse than useless ; neither has any good been ac- 
complished by transfusion of blood, inhalation of oxygen, or 
other special measures. 

PSEUDO-LEUKAEMIA. 

Pseudo-leukaemia, Hodgkin's disease, splenic anaemia, general 
lymphadenoma, adenia, is very closely related to leukaemia, 
presenting hyperplasia of the lymph glands and splenic enlarge- 
ment, with anaemia, but there is only slight increase, or no in- 
crease, of white blood corpuscles. 
74 



1170 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

./Etiology.— Nothing definite is known of the essential cause. 
Some writers think pseudo-leukaemia of infectious origin, 
others consider it due to local irritation, while still others at- 
tempt to establish a connection with syphilis and malaria. In 
the majority- of cases the approach of the affection is insidious 
and without apparent cause. It is a disease of the young 
rather than the aged, and three-fourths of the cases have oc- 
curred in men. 

Morbid Anatomy.— There is enlargement of the lymphatic 
glands, now hard and firm, then soft. At first the individual 
glands are well defined and freely movable ; later they form 
large agglutinated masses, covered by firm, dense tissues. In- 
flammatory adhesion to the overlying skin is common ; or the 
investing capsule may be broken, allowing the invasion of con- 
tiguous structures. While superficial glands occasionally sup- 
purate, there is in the main slight tendency, especially in the 
deeper glands, to suppuration or degeneration. Upon section 
the tumor proves to consist of a nodular mass of adhering 
glands of a gra3 T ish or grayish-red surface; the microscope 
shows extensive proliferation of lymph cells wholly obscuring 
the reticulum. Usually the superficial glands (cervical, axillary, 
inguinal) are attacked ; sometimes intervening groups escape ; 
again, the deep-seated glands, especially the mediastinal and 
retroperitoneal, suffer most. Enlargement of the spleen occurs 
in three-fourths of all the cases studied, but it seems slight 
when compared to the splenic enlargement of leukaemia. The 
marrow of the long bones may be rich in lymphoid tissues. 
Lymphoid growths are found very often in the spleen, the tu- 
mors there frequently reaching the size of a walnut ; they also 
occur in the liver, kidneys, lungs, tonsils and follicles, at the 
root of the tongue, in the intestines and upon the skin ; they 
may invade the spinal canal and give rise to paraplegia. 

Symptoms. — The onset of the disease is almost alwa3's grad- 
ual, attention being first called to a glandular enlargement, 
usually of the cervical glands on one side, the nature of which 
is not easily determined. Afore rarely the deep-seated glands are 
involved first, and then pressure symptoms are the first indica- 
tion of the trouble. The enlargement increasing, a tumor of con- 
siderable size forms, often producing startling deformity- by ob- 
literation of the neck and in extreme cases such extension of the 



PSEUDOLEUKEMIA. 1171 

growth as to lie over the clavicle, sternum and shoulder. Grad- 
ually, and with varying rapidity, other glands, as the axillary 
or inguinal, or the deep-seated glands, are involved. General 
health in the beginning is not affected, but after a time symp- 
toms of anaemia develop. The patient complains of palpitation 
of the heart, and examination demonstrates the presence of 
cardiac murmurs. Shortness of breath results from anaemia or 
from pressure upon the trachea, sometimes from pleuritic effu- 
sion. Fever is noticed in the majority of cases, even early; it 
may be of an irregular type or continuous, with evening exac- 
erbations. The urine may be albuminous. Enlargement of the 
spleen is not unusual; more rarely the thyroid and thymus 
gland is involved. Bronzing of the skin, intense pruritus, sec- 
ondary lymphatic tumors of the skin, and delirium and coma 
are among the less frequently observed symptoms. The blood 
presents no characteristic changes, but should nevertheless be 
frequently examined, since cases of this sort may assume the 
characteristics of a true leukaemia. A peculiar feature of the 
glandular enlargements is the fact that towards the end of life, 
and often during the febrile attacks, they diminish very mate- 
rially. 

A great variety of symptoms is caused by pressure of the en- 
larged glands upon adjacent structures or organs. Thus the 
cervical tumor may give rise to dysphagia from pressure upon 
the pharynx and oesophagus ; to dyspnoea from pressure upon 
the larynx and trachea, with paroxysms of asthma if the bi- 
furcation of the trachea is involved ; to disturbances of the 
heart, if the vagus is interfered with. Involvement of the bron- 
chial glands often causes distressing dyspnoea ; of the axillary 
glands, swelling of the arms ; of the abdominal glands, ascites 
and jaundice from pressure upon the portal vein and bile ducts ; 
of the inguinal glands, oedema of the lower extremities. Pres- 
sure upon the superficial veins may result in local oedema, dila- 
tation of the vein, and ulceration of the skin. Hoarseness is 
caused by pressure on the recurrent laryngeal; inequality of 
pupils from pressure on the cervical sympathetic; deafness 
from growth of adenoid tissue in the pharynx. 

Diagnosis. — In the early stage of the disease it is important 
to determine, if possible, the nature and cause of the glandular 
enlargement. Tubercular adenitis especially must be considered. 



1172 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

The following points are to be remembered : The tubercular 
affection occurs oftener in the young ; the disease is limited to 
a single group and to one side (left cervical, left axillary), and 
may exist there for years without involving other groups ; the 
affected glands are less freely movable than in pseudo-leu- 
kaemia; the bunches are small, knotted together, and are prone 
to soften, degenerate, suppurate, while in Hodgkin's disease 
suppuration occurs rarely, and then only in large and usually 
in superficial masses. Tubercular adenitis, furthermore, is 
more likely to involve the submaxillary glands than those of 
the anterior and posterior cervical triangles. The constitu- 
tional symptoms and the history of the case may afford valua- 
ble information. If the glandular enlargement is moderate and 
on one side, excision may be performed, giving an opportunity 
for conclusive histological examination of the structures. Ab- 
sence of anaemia and of pressure s\^mptoms, with persistency of 
the tumor, without extension, points toward benign 
lymphoma. If the lymphomata are leukaemic in character, ex- 
amination of the blood will determine that fact. 

Prognosis. — Recoveries are rare, and while in the early stage 
the patient should have the benefit of the doubt, little encour- 
agement can be given after the disease has reached an advanced 
stage. Extensive involvement of the deep lymphatics adds 
much to the gravity of the outlook. In acute cases, where 
there is rapid involvement of successive groups of glands, death 
may occur in a few weeks, certainly in a few months. In 
chronic cases the duration of the disease is several years, and 
not infrequently the tumors cease to grow and even diminish 
materially with temporary improvement of the constitutional 
condition. In very exceptional cases the}' may disappear. 
However, profound cachexia and anaemia, followed by dropsy, 
eventually develop, and death occurs from exhaustion or from 
the mechanical effects of compression, possibly from haemor- 
rhage or coma. 

Treatment. — If the patient is seen early, while the enlarge- 
ment of the superficial glands is still small, excision should be 
performed promptly ; later on, an operation is worse than use- 
less. Constitutional treatment is that of anaemia and leukae- 
mia. Arsenic is by the highest authorities credited with being 
the only remedy capable of promoting absorption of the lym- 



ADDISON'S DISEASE. 1173 

phomata. Emphasis is placed upon giving the drug in doses of 
one-fifteenth of a grain, or larger, of arsenious acid three times 
daily, for a long time, with, of course, the usual precautions 
against the development of toxic effects. Injection of arsenic 
directly into the gland is also recommended. "Each day there 
should be injected into a gland not before treated a mixture of 
equal parts of fresh Fowler's solution and of a two per cent, so- 
lution of carbolic acid in water. The first dose should be four 
drops, and an additional drop should be added daily until 
twenty drops are reached or toxic symptoms are produced. 
There may be no immediate disturbance, or there may be local 
pain for some hours afterwards. Cutaneous inflammation or 
abscess may follow, or temporary enlargement of the gland 
and oedema. As an immediate result of the treatment the pa- 
tient may suffer from a bad taste in the mouth, a burning in 
the throat, thirst, loss of appetite, nausea and vomiting, diar 
rhoea, abdominal pain, and jaundice. The temperature and 
pulse may rise. These symptoms demand temporary cessation 
of the treatment. If the glandular swelling return, a renewal 
of the treatment is indicated" (Wood and Fitz). Struempell 
claims to have seen apparent benefit from associating with the 
arsenic treatment, internally, inunctions of iodoform (1 part to 
15 of vaseline) over the tumor. Gowers and others recommend 
phosphorus when arsenic cannot be borne or has proved use- 
less. The necessity of supporting the strength of the patient by 
all means at our disposal is evident ; to this end cod-liver oil, if 
well borne, is exceedingly useful. 



ADDISON'S DISEASE. 

An affection characterized by a peculiar pigmentation of the 
skin, extreme debility, cachexia and, usually, (tubercular) dis- 
ease of the supra-renal capsules. 

Etiology .—Addison's Disease is rare, particularly in America. 
It is seen in men at least twice as often as it is in women, and 
generally occurs between twenty and forty years of age. The 
aetiology is quite obscure. It is held by many that the disease 
is primarily an affection, usually tubercular, of the supra-renal 



1174 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

glands. These in a normal state are presumed to furnish a se- 
cretion or extract which is essential to normal metabolism; 
this function having been destroyed by disease, there is thought 
to result either a toxic condition of the blood or a profound 
general atony or apatlry (Rolleston). Others hold that the 
real trouble lies in the nervous system, and rest their belief upon 
the frequent occurrence in Addison's disease of degenerative and 
inflammatory changes of the solar plexus. It is, however, evi- 
dent that in this strange affection the supra-renal glands are 
diseased much oftener than is the solar plexus, and that the 
changes in the latter are neither characteristic nor present in a 
large number of cases. It is even admitted that cases of Addi- 
son's disease have occurred in which neither supra-renal cap- 
sules nor solar plexus were involved. It is thought that in 
some cases the disease followed injuries. 

Symptoms. — Pigmentation of the skin is the most conspicu- 
ous S} 7 mptom. Its seat is the Malpighi and the corium. It va- 
ries from a light yellow to a deep brown or even black, and in 
typical cases has the true greenish-brown, bronze tint. It is, of 
course, first noticed on the exposed parts of the body, the face 
and the back of the hands, and on surfaces naturally most pig- 
mented (nipples, scrotum, penis) ; it commonly affects the mu- 
cous membrane (mouth, conjunctiva, vagina) and often the 
serous membrane. The sclera and nails, as a rule, escape, as may 
also the palms of the hands and the soles of the feet. Atrophy 
of the pigment is at times seen in patches (leucoderma). Pig- 
mentation is absent only in very rare cases. 

In man}' cases, before the appearance of pigmentation, gas- 
tric disturbances have begun to annoy the patient, and he ma}' 
suffer severely, even early in the course of the affection, from 
nausea, severe vomiting and gastro-intestinal catarrh. Com- 
plaint may also be made of rheumatoid pains. More charac- 
teristic, however, than the gastro-intestinal disorder is the pro- 
found prostration which exists throughout the course of the 
affection and which is out of all proportion to the comparative 
mildness of the constitutional symptoms. This prostration in- 
volves both body and mind, not only rendering a sustained 
physical or mental effort quite impossible, but making even a 
slight exertion absolutely burdensome ; even a trifling effort 
may be followed by panting, ringing in the ears and dizziness. 



addison's disease. 1175 

Anaemia, which by Addison was considered a highly important 
symptom, is not, according to later observers, prominent or se- 
vere. The pulse is small and rapid, and the action of the heart 
feeble. Fainting occurs often and from slight causes. The 
urine usually is normal ; there may be polyuria. 

Asthenia soon increases to an extent which forces the patient 
to remain in bed ; his intellectual and physical powers continue 
to grow weaker, his voice loses its natural ring, and death 
eventually occurs from exhaustion or heart failure. In excep- 
tional cases convulsions have been observed. 

Diagnosis.— The diagnosis of Addison's disease depends upon 
the existence, simultaneously, of the typical pigmentation and 
the characteristic extreme debility. It is necessary to bear in 
mind that pigmentation of the skin may result from other 
causes, as disease of the liver, tuberculosis, cancerous or lym- 
phomatous growths in the abdomen, melanotic cancer, exoph- 
thalmic goitre, pregnancy, disease of the uterus, or disease of the 
skin from irritation by dirt and vermin. Should a differentia- 
tion between these types of pigmentation become essential, 
close attention must be paid to its distribution and to the in- 
volvement, or freedom from involvement, of the oral mucous 
membrane. 

Prognosis. — In rapidly progressing (acute) cases death may 
occur within a few weeks. Oftener the disease runs a chronic 
course and, with occasional periods of improvement, life may 
be spun out for two or three years. Exceptional cases are 
recorded where life was prolonged even ten years. It is ad- 
mitted that the prognosis is practically hopeless, and reported 
cures are thought to rest upon an error in diagnosis. 

Treatment. — Absolute rest in bed is essential in cases of pro- 
found asthenia with tendency to fainting. The diet must be 
nourishing and easily digested ; milk is often kindly borne. 
Remedies likely to be of service are those suggested by the 
cachexia, anaemia and gastro-intestinal symptoms. 

Of late the profession have been interested in the treatment of 
Addison's disease with the extract of the supra-renal capsules 
of animals, i. e. sheep and beef. Although the reports are some- 
what contradictory, results have in the main been encourag- 
ing. Ten grains of the supra-renal capsule of beef in glycerine 
may be injected hypodermically each day, or the patient may 



1176 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

be directed to eat three times each da3' two uncooked adrenals 
of sheep or half a gland from a steer, or take five grains of the 
dried gland, three times daily in capsules. The gland may be 
eaten cooked, if desired. 

Just how much, or how little, remedies acting under the law 
of similars are capable of doing, cannot be determined until 
more extensive clinical experience has accumulated. The fol- 
lowing should be consulted: Belladonna. In acute cases, with 
much pain in the back and loins ; tenderness in the epigastrium 
and hypochondrium, with much vomiting and characteristic 
diarrhoea and nervous S3 r mptoms. — Calcarea carbonica. In 
chronic cases, with excessive muscular debility, headache, ver- 
tigo, fainting. Gastric catarrh, with epigastric and abdominal 
tenderness and tendency to constipation. Pressing pain in kid- 
neys and loins. Scrofulous or tubercular tendency. — Natrum 
muriaticum. Remarkable impairment of nutrition. Great men- 
tal and physical prostration ; trembling of the legs ; anorexia ; 
loathing of meat ; vertigo on rising from bed and trying to 
walk. Strumous diathesis. Periods of irritability, with gen- 
eral despondency. — Phosphorus, according to Payr, when 
there is sickly yellow color of the face, with sunken features and 
eyes. Great exhaustion, coming on suddenly, with fainting. 
Headache, vertigo, sleeplessness, despondency, irritability; burn- 
ing, cutting, pressing pains in the stomach ; nausea and char- 
acteristic vomiting ; diarrhoea or constipation. Weakness and 
lameness in the small of the back ; weakness in the extremities ; 
twitchings and spasms. 

Ferrum, Iodium and Arsenicum should also be studied. 



DISEASES OF THE THYROID GLAND. 

GOITRE. 

Goitre or hypertrophy of the thyroid gland occurs sporadi- 
cally almost everywhere, and endemically in some parts of the 
world, especially in mountainous countries; in Europe it is en- 
demic in Switzerland. It is not a very common disease in 
America. The statement is made that an unusual number of 
cases are seen in the strips of country bordering upon the great 



GOITRE. 1177 

lakes, especially in Michigan. A residence of many years in that 
country makes me doubt the correctness of the statement. 

It is not positively known "what causes goitre, although 
many observers still hold that some quality in the drinking 
water is responsible for its existence. Heredity undoubtedly is 
a factor. The greater number of cases occur in women, espe- 
cially in young girls at the age of puberty. This fact, together 
with the temporary enlargement of the gland which may often 
be seen during menstruation, has suggested a possible connec- 
tion between the reproductive system and goitre. 

Three varieties maybe distinguished: Parenchymatous goitre, 
in which the substance of the gland is enlarged by new growth 
of follicles; these may undergo hyaline, gelatinous or colloid 
degeneration, masses of which occupy parts of the tumor (col- 
loid goitre). The vascular form is due to dilatation of the 
blood vessels or to an excess of vascular tissue, with no new 
formation of glandular tissue. In cystic goitre the gland is oc- 
cupied more or less extensively by cysts, often of large size, 
containing, usually, liquid contents ; the walls of the cysts may, 
or may not, undergo calcification. 

Symptoms. — Unless pressure effects are caused, which would 
be the case only in a tumor of considerable size, a person may 
have goitre for many years without observing a single un- 
pleasant symptom; cases are not rare of old people who 
through life have carried a large goitre without ever experienc- 
ing more than a trace of difficult breathing. The commonest 
pressure symptom is dyspnoea from compression of the 
trachea ; less often there is difficulty of swallowing from com- 
pression of the oesophagus; narrowing of the pupil is occasion- 
ally seen from pressure on the sympathetic. Should the goitre 
pass beneath the sternum, pressure on the veins may result in 
fatal thrombosis. Exceptionally death occurs suddenly, prob- 
ably from sudden compression of the trachea or from paralysis 
of the vocal cords. 

Prognosis. — In young people, especially in young girls, goitre 
may get well of its own accord, provided there is no degenera- 
tion of the gland ; in the far greater number of cases it exists 
through life. 

Treatment. — In deference to the possible connection between 
drinking water and goitre, it is well to insist upon change of 



1178 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

drinking water or at least upon boiling the water used for 
drinking purposes. It is not denied that cures have been 
affected by taking these precautions. If degeneration of 
structure has taken place, the case should at once pass into the 
hands of the surgeon. No degeneration of structure existing, 
medical treatment may be attempted, and with the reasonable 
hope of accomplishing a cure. 

Spongia tosta has for centuries had a reputation for curing 
goitre ; this it still maintains among homoeopaths. Cures have 
been reported with a large range of attenuations, but the low 
triturations of the burnt sponge are probably preferable. — 
Iodine has probably cured more simple goitres than any other 
remedy, and is still a favorite prescription with many practi- 
tioners. It should be given in a low attenuation and for a con- 
siderable length of time. If used externally as well, it is best 
prescribed as an ointment ; painting the surface with the tinct- 
ure is useless. — Calcarea carbonica is highly recommended by 
Proll, Ebstein, and others, and acts best when there are present 
characteristic constitutional indications with evidence of mal- 
nutrition and general tendency to glandular enlargements. It 
is claimed that even in cystic goitre excellent results have been 
obtained from its exhibition, particularly when prepared from 
the egg-shell. — Phytolacca. According to Lilienthal and 
others it is indicated in "nodulated goitre ; glands of the right 
side of the neck swollen ; jerking, shooting, lancinating pains, 
worse in damp weather and at night." 

Treatment with the extract of the thyroid gland is becoming 
fashionable; von Bruns, of Tuebingen, reports a series of cases 
in which excellent results were obtained. To adults he gives 
ten grains of the fresh thyroid, once each week; to children, five 
grains. Injections, deep into the gland, of twenty to thirty 
minims of a five-per cent, watery solution of carbolic acid have 
been used with good success by Haven, of Chicago. "Usually 
it causes a contraction and a hardening of the connective tissue 
of the tumor, and a gradual lessening of the blood supply, and 
in the course of eight or ten weeks a complete disappearance." 
The injection causes slight pain, but is followed by some dizzi- 
ness which, however, soon disappears. 

Electricity may be emplo3^ed to advantage ; in fact, in mam- 
cases it has proved the most satisfactory method of treatment. 



EXOPHTHALMIC GOITRE. 1179 

A galvanic current of from five to fifteen milliamperes may be 
passed through the tumor ; or the cathode may be placed on the 
tumor and the anode in the auriculo-maxillary angle ; or electro- 
lysis may be used. The latter, according to Walling, is per- 
formed as follows : The parts are washed and may be injected 
with cocaine. Place a large anodal pad on the shoulder, or 
near by, and thrust one or more needles boldly into the tumor, 
until the insulation is beneath the skin. Gently turn on the cur- 
rent until you get five, ten, or even more, milliamperes ; let it run 
for from two to five minutes, and the operation is over for that 
time. The cathodal needles must be held in place, or their 
weight will cause them to fall out. If the tumor is dense and 
very unyielding, rendering the introduction of the needles diffi- 
cult, push them through the skin, turn on the current, and then 
press them in as far as you wish. Repeat the operation in five 
or seven days, but in another place ; it is free from danger and 
causes but little pain. ( 

EXOPHTHALMIC GOITRE-BASEDOW'S DISEASE- 
GRAVE'S DISEASE. 

An affection characterized by acceleration of the pulse, hyper- 
trophy of the thyroid gland, and exophthalmus. 

Etiology. — The disease is not peculiar to any climate or 
country, nor does it occur with unusual frequency in countries 
where goitre is common. It is seen much oftener in women 
than in men, rarely begins before the twentieth or much after 
the thirtieth year, and is not infrequently seen in several mem- 
bers of the same family. It very often appears closely con- 
nected with profoundly depressing influences, such as violent 
grief, worry or fright. As yet, its essential cause is not known. 
Many consider it of purely neurotic origin ; in support of this 
view emphasis is placed upon its close relation to profound 
emotions and moral influences, the well developed neuropathic 
tendency (hysteria, epilepsy, etc.) which is unmistakable in 
families who furnish several victims, and the absence of clearly 
defined lesions. On the other hand, in several examinations 
after death the medulla oblongata was found the seat of struct- 
ural changes, and this fact has suggested the medulla oblon- 
gata as the possible cause of the mischief. The most popular 



1180 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

theory at present is that first advocated by Moebius (1891), 
who considers Grave's disease the result of a toxaemia arising 
from morbid activity of the thyroid gland. The antithesis ex- 
isting between exophthalmic goitre and myxcedema, which 
yet clearly shows that the morbid action expends itself in the 
same channels ; the fact that the extract of thyroid gland in 
overdoses, when given in health or for myxcedema, often pro- 
duces symptoms of exophthalmic goitre ; and the occurrence of 
both affections in the same families, with the occasional tem- 
porary improvement from removal of the thyroid gland, are 
plausible arguments in favor of the teaching of Mcebius. 

Symptoms. — The disease is essentially slow and deliberate in 
its onset and chronic in its duration. Exceptions occur in 
which the onset is sudden and the course very rapid. Such is a 
case related by von Graefe, where a young man, laboring under 
terrific sexual excitement, struggled for a half hour to gratify 
his passions, and then fell into a state of corresponding exhaus- 
tion ; on the next morning there was noticeable protrusion of 
the eye-balls, and within a week the exophthalmus was terri- 
ble. Trousseau also relates a striking case, that of a woman of 
advanced years who was plunged into violent grief by the 
death of her husband. One night, when worn out by weeping 
and watching, she felt her eyes protrude to such an extent that 
she could not close the lids ; this was accompanied with palpi- 
tation of the heart, sense of enlargement and throbbing in the 
anterior neck, and epistaxis which continued all night. Trous- 
seau saw the patient four days later and found her a t3 r pical 
case of Grave's disease. 

Usually, however, the disease comes on almost imperceptibly, 
the patient complaining of nervousness and disturbances of the 
circulation. There is much palpitation of the heart, with great 
increase of the cardiac impulse and throbbing and pulsating of 
the vessels, which is plainly noticeable in the superficial vessels ; 
this tumultous action of the heart is easily brought on or in- 
tensified by slight emotional excitement, and may be readily 
seen in the carotids and abdominal aorta; the heart sounds can 
often be easily heard at some distance from the patient. Car- 
diac hypertrophy is a common feature of long-standing cases. 
The pulse is rapid, at first from 90 to 100 beats per minute, but 
gradually increasing to 125 or 150, or more; it is quickly and 



EXOPHTHALMIC GOITRE. 1181 

immensely accelerated by any excitement. Protrusion of the 
eye-balls follows soon, due to a material increase of blood and 
lymph in the orbit; hence the suddenness with which it may ap- 
pear, the difference at different times in the degree of the pro- 
trusion, and the disappearance of the symptom after death. 
Permanent exophthalmos may result from large deposits of fat 
within the orbit. In extreme cases the eye-balls may be forced 
from the sockets. In the great majority of cases vision and 
pupils remain normal. Close study by specialists has developed 
some signs which are frequently found. Thus, at first a rim of 
white is seen above and below the cornea, and it is soon ob- 
served that there is less winking than in health. Von Graefe 
called attention to the stiffness of the upper eye-lid and its in- 
ability to follow the downward movement of the eyeball. 
Stellwag pointed out an enlargement of the palpebral aper- 
ture from retraction or spasm of the upper lid. Mcebius 
noticed a lack of convergence of the two eyes. Not all or any 
of these may be present. Pulsation of the retinal arteries was 
detected by Becker in five cases out of six. Corneal opacity and 
ulceration may result from exposure and great dryness of the 
parts and from trophic disturbance. Exophthalmus is usually 
bilateral and of like degree. Thyroid enlargement takes place, 
rarely with the appearance of palpitation, and then chiefly in 
the very acute cases ; more frequently it develops weeks or 
months later. The swelling is smooth, firm, elastic, may in- 
volve one lobe, preferably the right, or the entire gland, and 
rarely attains the size of the common goitre. Knotted veins 
and distended arteries are often seen under the skin ; the whole 
gland may pulsate; palpation detects a thrill, and ausculta- 
tion easily perceives the bruit de diable. Osier attaches espe- 
cial value to an involuntary, fine tremor, about eight to the 
second. Colloid and other degenerative changes may take place 
in protracted cases. 

With the progress of the disease the patient becomes anaemic 
and feverish, loses flesh, and suffers more or less from nervous 
irritability. The disposition changes for the worse ; peevishness 
and mental depression render it difficult to please ; often a truly 
neurasthenic condition obtains ; muscular tremors and weak- 
ness, with heaviness and weariness and lack of supporting 
power, make life trying. Hysteria, epilepsy and mania occur, 



1182 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

the latter particularly in cases which progress rapidly toward 
a fatal termination. Women suffer much from menstrual irreg- 
ularities, often with a profoundly anaemic and chlorotic state. 
Vomiting and diarrhoea, especially the latter, occur throughout 
the course of the disease, and the intestinal flux may recur with 
great regularity at stated intervals. Many patients suffer 
keenly from throbbing in the arteries, and are subject to 
flashes of heat, followed by profuse perspiration. Passing 
erythema on the face, neck and shoulders, brought on from 
slight irritation, is frequently observed; "tache cerebrate" 
(Trousseau), a short-lived redness, from capillary engorgement, 
following a slight local irritation, such as passing the finger 
nail over the flesh, is common, but not of diagnostic value. The 
skin is often rough and dry ; urticaria is not unusual ; scler- 
oderma and pigmentation, as in Addison's disease, occur rarely. 
Glycosuria and albuminuria are sometimes seen. 

From extensive observation Charcot asserts that patients 
suffering from exophthalmic goitre show a great lessening of 
electric resistance, and Joffroy points out that if the patient be 
directed to hold the head down and look up without raising it, 
the forehead remains smooth instead of wrinkled, as it natur- 
ally would be. 

Diagnosis. — No difficulty can be experienced when tachycar- 
dia, thyroid enlargement and exophthalmus are all present. 
In cases, however, which run a very tedious course, and in 
which the appearance of exophthalmos is delayed for years, or 
the enlargement of the thyroid gland is trivial and possibly 
wholly wanting, time is an important element in the diagnosis. 
Cases are on record in which the true nature of the disease was 
not recognized until after many years of observation and the 
final characteristic grouping of the cardinal symptoms. 

The duration of the affection is indefinite, usually covering 
several years. Acute cases are exceptional and serious ; yet re- 
covery after a short illness has occasionally been put on record. 
Sometimes great improvement and even recovery take place 
after a case has run for six months or a year. If fully devel- 
oped, the prognosis is unfavorable. Death occurs from 
asthenia, acute mania, or some intercurrent disease. 

Treatment. — The general treatment consists of rest, which 
in severe cases must be absolute, good feeding, massage, absti- 



EXOPHTHALMIC GOITRE. 1183 

nence from all stimulants, including tea and coffee, and of 
everything likely to worry or excite the patient. Many Euro- 
pean writers advocate an occasional prolonged residence in a 
mountainous district, at an elevation of three to five thousand 
feet, especially in the Alps ; American clinicians prefer the sea- 
shore. The excited state of the heart usually demands means 
for its relief ; it is, however, generally admitted that, with the 
possible exception of strophanthus and digitalis, cardiac reme- 
dies accomplish little, if any, permanent good. The occasional 
use of an ice bag or of Leiter's coil over the heart or over the 
lower part of the neck and manubrium affords more direct re- 
lief, usually and promptly reducing the tumultuous action of 
the heart and the rate of the pulse ; it is, however, only of tem- 
porary benefit. Belladonna in increasing doses has in some 
instances proved helpful. The treatment with thyroid gland 
(sheep) has been tested extensively, and alleged cures have been 
reported ; but the concensus of opinion on part of the best clin- 
icians is adverse to the claims made for it. Electricity has ac- 
complished more than other special lines of treatment. Vig- 
ouroux recommends the faradic current. He applies it by 
means of a large anode to the back of the neck and a smaller 
cathode over the sympathetic ganglia in the front of the neck, 
" afterwards shifted to the motor points of various muscles of 
the face and neck, and still later replaced by a large cathode 
placed over the heart region and the sternum, a very strong 
current being used to the sympathetic, a weaker one to the 
heart region." Others prefer the galvanic current, placing the 
cathode just behind the angle of the jaw and the anode over 
the heart or upper sternum. The strength of the current 
should be sufficient to produce slight pain, the seances should 
be short, and the treatment continued for months. Surgical 
methods used consist of electrolysis, ligation of the thyroid ar- 
teries, and partial excision of the thyroid gland. Jaboulay 
makes an incision in the median line, separates the gland from 
the trachea, and leaves it exposed, covered by a simple protec- 
tive antiseptic dressing ; he affirms that the exposed gland rap- 
idly shrinks in size. The wound is closed when the gland has 
returned to normal. 

F. Park Lewis (Arndt's System of Medicine) considers Bella- 
donna one of the most important remedies here. — Arsenicum is 



1184 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

useful when there is much anaemia and emaciation ; Lycopus 
Virginicus is b}' Lilienthal and Hale credited with having af- 
forded permanent relief of some of the most marked symp- 
toms; Spongia, Iodine, Secale, Natrum muriaticum, Amyl 
nitrite, Conium, and a score of other remedies, are suggested 
by various writers. The golden rule holds good which directs 
the exhibition of that remedy which is indicated by the totality 
of symptoms. 

MYXOEDEMA. 

A disease characterized by general swelling, resiliency and 
translucency of the integument, due to an overgrowth' of the 
subcutaneous connective tissue and infiltration of the same 
with a gelatinous or mucinous substance, accompanied with 
mental sluggishness and atrophy of the thyroid gland. The 
affection is seen chiefh r in women, rarely in children ; it may oc- 
cur in several members of a family and in conneccion with ex- 
ophthalmic goitre ; it may also follow goitre or coexist with 
goitre. 

Sporadic or congenital cretinism is not m3 r xoedema proper. 
Here the child is born dwarfed, thick-necked, short of limb, 
with protruding abdomen and a congenitally absent thyroid 
gland; the face is repulsive and abnormally large; the lips 
thick, the tongue clumsy, often protruding; the child is dull, 
even idiotic. In exceptional cases the thyroid gland is present 
and may even be materially enlarged. The characteristic myx- 
oedematous condition of the skin is, however, wanting. Myx- 
oedema proper occurs five or six times as often in women as in 
men. It is likely to be transmitted through the mother ; one 
daughter may have exophthalmic goitre, while her sister has 
myxoedema. No clear connection has been established between 
the sexual or reproductive function and myxoedema. 

There is marked increase in the bulk of the patient, with "fill- 
ing up" or puffing of the face, neck and other parts of the body, 
and supra-clavicular swelling. The parts feel firm, inelastic, 
and there is no pitting upon pressure, since the swelling is the 
result of actual increase in volume and density of the subcuta- 
neous connective tissue. There is no adhesion of the skin to the 
subcutaneous structures. The appearance and expression of 



MYXCEDEMA. 1185 

the face soon undergo a striking change. The face broadens 
out; the wrinkles are obliterated, thus destroying the natural 
expression ; the features grow coarse as well as broad ; the lips 
become thickened and the mouth heavy; the nostrils appear 
broad and flat ; the tongue becomes large, clumsy, and some- 
times assumes such proportions that it interferes with the 
swallowing of the saliva, which flows from the mouth in a 
constant stream. The color of the face changes to a chalky 
pallor, occasionally with bright red patches on the cheek. The 
skin is dry, rough, scaly and of brown appearance, and that of 
the hands especially is wrinkled and coarse. The nails become 
dry, brittle, atrophied, sometimes thickened, and frequently are 
lost. The hair undergoes similar changes, turns dry and 
coarse, and there is frequently loss of hair and of the teeth. The 
gait of the patient is now slow and cumbersome ; she grows 
stupid and phlegmatic in action and speech. The disposition 
changes, and she becomes irritable, morose, suspicious. Head- 
ache frequently is persistent. Failure of memory, delusions, 
hallucinations, chiefly of sight, muscular weakness, with 
numbness, neuralgic pains here and there, and loss of patellar 
reflex develop in the course of time. The pulse and tempera- 
ture usually are below the normal. There may be leukocytosis 
and haemorrhage from the mucous membranes. The urine 
may contain albumin and even casts; exceptionally there is 
glycosuria. The functions of the heart, lungs and abdominal 
organs are not disturbed. The thyroid gland in the meantime 
undergoes extensive atrophy and may be converted into a 
small fibrous mass. 

The progress of the disease is slow, covering a period of 
many years, not infrequently ten or fifteen years, death usually 
taking place from some intercurrent disease, oftener tuberculo- 
sis. 

The so-called operative myxoedema results from the total, 
less often the partial, extirpation of the thyroid gland. It pre- 
sents in the main the same train of symptoms, and because of 
its infrequency is of slight practical interest. 

Treatment. — The patient should be kept at an even tempera- 
ture and in a warm climate, on account of the habitual intoler- 
ance of cold. Frequent warm bathing and shampooing are 
highly beneficial. 
75 



1186 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

The only direct treatment which so far has yielded positive 
results is the method introduced by Horsle}' and Murrey of in- 
jecting, subcutaneously, thyroid gland extract, modified later 
by Hector Mackenzie and Howitz to feeding the gland itself. 
This treatment has passed the experimental stage and consti- 
tutes one of the positive advances of modern medicine. The 
powdered gland or the glycerine extract may be used. The 
most approved way is to commence with one grain of the pow- 
dered gland, three times a day, gradually increasing the dose 
until the maximum dose of ten or fifteen grains has been 
reached. If there is positive improvement and the limit of the 
improvement has been attained, which must be determined ex- 
perimentally, the treatment may be discontinued for the time 
being, to be resumed in moderate doses in order to maintain 
normal metabolism. One of the most reliable indications for 
the prompt resumption of treatment is a feeling of coldness on 
part of the patient. The evidence of beginning improvement 
lies in a loss of weight, increased warmth of the body, normal 
state of pulse and temperature, and brightening of the intellec- 
tual faculties. It requires some experience to determine when 
to discontinue treatment ; physicians who lack this experience 
must not forget that the action of thyroidin is cumulative. 

While ill effects are comparatively rare, they nevertheless oc- 
cur ; the tendency at present is to wholly ignore them. A tem- 
porary aggravation is not unusual, consisting of excessive ner- 
vous excitement, rapid pulse, great irritation of the skin, often 
accompanied with severe delirium. To this state, which is 
transient, the term " thyroidism" is applied. When it occurs, 
treatment must be stopped for a time. It has been shown that 
the juice of the thyroid gland may poison the heart, and in sev- 
eral cases death has resulted from the treatment. 

Especially gratifying is the large number of cases of cretinism 
which under the thyroid gland treatment have been materially 
and permanently improved. 



PART X. 

DISEASES OF THE KIDNEYS AND 
BLADDER. 



Diseases of the Kidneys and Bladder. 



DISEASES OF THE KIDNEYS. 



MOVABLE KID1VEY. 

Various degrees of mobility of the kidneys exist. There may 
be a displacement downward, just sufficient to allow recogni- 
tion of the lower edge of the kidney by palpation {palpable 
kidney) ; or it may be possible to grasp the upper edge and to 
hold the kidney down {movable kidney) ; or the organ may be 
freely movable and displaced so as to appear as low as the 
middle line of the abdomen {floating kidney). Permanent fix- 
ation in an abnormal position is possible. 

/Etiology. — A congenital predisposition to such a condition is 
based upon laxity of the supporting structures, as looseness of 
surrounding tissues, abnormal length of the renal artery, and 
laxity of peritoneal attachments. Usually movable kidney is 
acquired. It occurs from five to ten times as often in women 
as it does in men, is more frequent on the right side than on the 
left, and exceptionally may involve both kidneys. It is 
thought that the habit of tight lacing, as well as the relaxed 
condition of the abdominal walls from repeated pregnancies, 
accounts for the frequency of this accident in women. Wasting 
of fat about the kidneys ; injuries ; straining from heavy lift- 
ing ; dragging down by tumors ; displacements of the liver up- 
ward from great distension of the stomach, carrying the kid- 
ney with it, are each possible etiological factors. Sometimes 
movable kidney is associated with neurasthenia, especially in 
chlorotic young girls, characterized chiefly by gastro-intestinal 



1190 DISEASES OF THE KIDNEYS AND BLADDER. 

disturbances and displacements of stomach, liver, intestines or 
uterus. 

Symptoms. — Frequently the patient is wholly unconscious of 
trouble. There may be a sense of discomfort and dragging- 
down ; or there may be experienced drawing pain in the abdo- 
men, with shooting into the epigastric, lumbar or sacral region, 
or darting upward into the intercostal region, simulating neu- 
ralgia ; again there may be colicky pain. Whatever the kind of 
discomfort felt, it often is brought on by a motion, change 
in position, stooping, or jar — as from riding — and is usually re- 
lieved by lying down and resting. In the cases associated with 
a neurasthenic state gastric disturbances, closely resembling 
nervous dyspepsia, are quite common, and to these are added 
symptoms of nervous irritability-, such as pain in the head and 
back, moodiness and peevishness, paresthesia, etc. A tendency 
to hypochondriasis in men and hysteria in women is often 
strongly pronounced, and it is on this account that such pa- 
tients, always inclined to magnify even trifling ailments, should 
be kept in ignorance of the existence of a movable kidney. The 
association of movable kidney and dilatation or depression of 
the stomach is frequent. Glenard applied the term enteropto- 
sis to the cases in which movable kidney is associated with di- 
latation of the stomach, displacement of abdominal viscera, 
nervous dsiturbances, and nervous dyspepsia. Occasionally 
there are observed paroxysms of severe abdominal pain, with 
nausea, vomiting, chills, fever and collapse, possibly with great 
sensitiveness to pressure and perceptible swelling in the region 
of the displaced kidney ; these were first described by Dietl 
(DietVs crises). Their cause is not clear; possibly they result 
from kinks or twists in the renal vessels. They often are accom- 
panied by acute hydronephrosis. During these crises, called 
" incarceration symptoms " by Dietl, the urine usually is dimin- 
ished in quantity, sometimes becomes bloody, and when there 
is pyonephrosis, it contains pus. The paroxysm having passed 
away, the urine again becomes abundant. 

Diagnosis. — The diagnosis rests upon the recognition of a 
distinctive, firm, kidney-shaped tumor — easily escaping from the 
hand and readily pushed back into its normal position — either 
just below the edge of the ribs or toward the umbilicus or in 
the inguinal region. To recognize this tumor, bi-manual pal- 



MOVABLE KIDNEY. 1191 

pation should be practiced, with the patient in the dorsal posi- 
tion and with head down and legs well drawn up, the physi- 
cian's left hand in the lumbar region between the eleventh and 
twelfth rib, the right hand in the hypochondriac region, just 
under the edge of the liver, in the line of the nipple. If unsuccess- 
ful in this position, a change to the knee and chest, or some 
other, position may reveal the tumor. Not infrequently the pa- 
tient knows from experience just what position to assume for 
the purpose of finding the tumor. An enlarged gall-bladder, a 
faecal mass, or pedunculated ovarian, or uterine tumor or ab- 
dominal growth may be mistaken for a movable kidney. 

The prognosis is favorable as to life. Recovery may take 
place, even alone from such improvement in general health as 
may restore vigor to relaxed supporting tissues. Or a case 
may continue indefinitely without giving rise to the slightest 
trouble, especially if the kidney eventually becomes fixed. 

Treatment. — In the very exceptional cases where the kidney 
is displaced by a strain or similar injury and the physician is 
called at once, it is usually possible to replace the organ and by 
enforcing absolute rest in the recumbent position to perma- 
nently cure the case. Generally speaking, mechanical supports 
are indispensable. "The best bandage is made of silk elastic 
closely fitted to the whole abdomen of the patient, and pre- 
vented from riding up by means of straps of soft rubber tubing 
or similar material, one on each side, passing from back to front 
between the legs. Over the position of the dislocated kidney is 
sewed on the inside of the bandage a round pocket of soft 
chamois skin, left open above, so that a pad can be pushed into 
it and changed on occasion. Success depends very largely upon 
the skill of the maker in fitting and adjusting and the patience 
of the subject in enduring annoyance until habit has produced 
toleration." (Wood and Fitz). 

Medication, by its effects upon the general health, is often of 
benefit, as in persons of a gouty tendency, in which case the 
diet also must be properly regulated. Surgical procedures are 
applicable only to exceptionally severe cases. They consist of 
removal of the kidney (nephrectomy), an operation which has 
made a bad record, and nephrorrhaphy (stitching the kidney to 
the posterior abdominal wall) first made by Hahn, and since 
then practiced successfully by many surgeons. 



1192 DISEASES OF THE KIDNEYS AND BLADDER. 

CONGESTION OF THE KIDNEYS. 

Acute Congestion or hyperemia of the kidneys consists of an 
active engorgement of the renal blood vessels without changes 
in the tissue of the kidneys. It may result from overexertion, 
from cold, from the ingestion of certain poisons (cantharides, 
turpentine, cubebs, copaiba), severe injuries, surgical opera- 
tions and extirpation of one of the kidneys. It is characterized 
by diminution, sometimes suppression, of urine ; the urine 
voided may contain blood, albumin and casts, with no mate- 
rial change in its specific gravity. Rest in bed, liquid diet and 
the application of the hot pack, for the purpose of bringing on 
sweating, are indicated, with such remedies — Aconite, Arnica, 
Belladonna, and others — as are suggested by the totality of 
symptoms. 

Chronic Congestion or mechanical hyperemia results from 
general or local causes. To the former belong chronic diseases 
of the heart and lungs with obstructed circulation ; to the lat- 
ter, pressure upon the renal veins from tumors, pregnant 
uterus, ascites, thrombi or cicatricial stenosis. The morbid 
anatomy is practically that of diffuse nephritis. "The organ is 
often somewhat enlarged, it feels firmer than normal, and 
shows, both on its surface and on section, a dark bluish-red 
color — cyanotic induration. The medullary substance is usually 
darker than the cortex. Under the microscope we see consid- 
erable dilatation and a tense fulness of the veins and capilla- 
ries. The parenchyma is normal, but in more advanced cases it 
may show a beginning of fatty degeneration of the epithelium, 
which is the result of the defective arterial blood supply. Inter- 
stitial changes are usually absent" (Struempell). 

Symptoms. — The urine is scanty, dark, concentrated, of high 
specific gravity, and shows a sediment of uric acid and urates ; 
it may be slightly albuminous, contain a few hyaline casts, and 
occasionally scattering white and red blood corpuscles, indica- 
tive of slight bleeding. 

Treatment is of necessit}^ directed to the primary difficulty ; 
if the latter is incurable, the congestion continues to the termi- 
nation of the case. Temporary improvement under the exhibi- 
tion of appropriate measures is frequent. 



ANOMALIES OF THE URINE. 1193 

A^OMAI^IES OF THE URI1ME. 

Anuria means total suppression of urine ; the term oliguria is 
used to express an abnormally small secretion of urine in the 
twenty-four hours. Both partial and complete suppression, 
more often the former, occur in acute nephritis. Anuria may 
also result from colds, especially in children; from acute poison- 
ing by phosphorus, lead, cantharides, turpentine, mineral 
acids and irritants; it is a feature of collapse (shock, injuries in 
operations), occurs often in acute diseases as they approach a 
fatal termination (yellow fever, cholera, typhus, small-pox, 
etc.), is known to have followed the use of the catheter, and oc- 
casionally occurs in connection with hysteria. It may be ob- 
structive, from blocking of the ureters by renal stone. In the 
absence of special complications the patient may live for many 
— eight to eleven — days, and present no symptoms of poisoning. 

The treatment of obstructive anuria is wholly surgical. In 
other forms hot applications over the loins must be persistently 
kept up. Cupping is often of benefit. The bowels are to be 
kept open. Profuse sweating by the subcutaneous use of pilo- 
carpine (gr. 14 to Y 3 ) is an important aid ; the administration of 
the drug may be preceded by some stimulant, as gin in water 
or aromatic spirits of ammonia (thirty drops in water). Re- 
spiratory embarrassment counter-indicates the use of pilocar- 
pine. The selection of the remedy depends largely upon the na- 
ture of the primary cause ; thus, the entire series of remedies 
under nephritis, yellow fever, typhus, etc., may have to be con- 
sulted. The more important are : Arsenicum, Apis, Digitalis, 
Mercurius, Terebinthina, Rhus, Argentum nitricum, Cro- 
talus, Lachesis, Phosphorus. Aconite is to be especially 
considered in anuria resulting from exposure to cold ; Arnica, 
when due to mechanical injury ; Helleborus, Apocynum, 
Apis, when complicated with dropsy. 

Hsematuria. — Bloody urine occurs in connection with affec- 
tions of the kidneys (active congestion, inflammation, stone, in- 
farctions, new growths) and urinary passages (injuries of 
urethra or ureters from the passage of a stone, ulceration or 
malignant disease of the bladder, rarely in gonorrhoea) ; from 
injuries (fall or blow upon the back, catheterism) ; from acute 
poisoning with turpentine, carbolic acid, cantharides; in the 



1194- DISEASES OF THE KIDNEYS AND BLADDER. 

course of acute specific fevers (yellow fever, small-pox, ma- 
laria) ; in constitutional diseases (scurvy, purpura, etc.) ; from 
the presence of parasites (filaria sanguinis hominis and Bilhar- 
zia haematobia). Exceptionally no cause can be assigned or im- 
pairment of general health found ; this applies especially to the 
occasional bleeding in young persons, at times undoubtedly vi- 
carious, spoken of by Gull as "renal epistaxis." 

The diagnosis rests upon the recognition of the presence of 
blood in the urine, which in appearance varies from a faint 
smoky color to a bright red or deep chocolate or porter color. 
Microscopic and spectroscopic examination may be necessary. 
The guaiacum test is reliable and simple ; equal parts of old oil 
of turpentine, ozonized by exposure to light and air, and of the 
tincture of guaiacum are placed into a test tube ; on the sur- 
face of this mixture an equal part of the urine to be tested is 
floated. In the presence of haemoglobin there is formed a 
bluish-green ring which soon assumes a beautiful blue. If the 
haemorrhage comes from the kidney, the blood and urine are 
usually intimately mixed ; the blood is more often clotted, and 
there may be moulds of the ureters or renal pelvis, especially if 
the haemorrhage is copious and the flow somewhat impeded ; 
the blood is dark, with a brownish sediment ; often pain in the 
renal region ; tube casts. If from the bladder, pain and uneasi- 
ness when passing urine ; urine at first clear ; blood appears to- 
ward the last ; if the bladder is washed out, the water is blood- 
tinged at first, then gets clear; the reverse is the case if the kid- 
ney is the seat of the bleeding. If from the urethra, the blood 
escapes in drops and without reference to micturition. As a 
general rule, the bleeding is not severe or constant when haema- 
turia occurs as a feature of inflammatory or infectious disease, 
but persistent and copious when from cancer or new growths 
generally. 

Treatment embraces absolute rest, measures to keep the 
bowels open so as to avoid straining at stool, and the use of 
cold applications (ice-bags, cloths wrung out of ice-cold water). 
In renal haemorrhage the hips should be raised high. If from 
the bladder and due to fissures, astringent injections often are 
helpful ; if profuse, from the neck of the bladder, the introduc- 
tion of a soft catheter, which is allowed to remain, is highly 
recommended. If the bladder is filled with clots, these mav be 



ANOMALIES OF THE URINE. 1195 

broken up by the injection of peroxide of hydrogen or of pepsin 
or papoid, and can then be discharged through the catheter. 
Keyes insists that the clots should be let alone. Injections of 
hamamelis, several ounces in equal parts of water, are exceed- 
ingly useful. Hamamelis, given by the mouth, in doses of from 
thirty to ninety drops of the fluid extract, and ergot, in three- 
grain doses, several times during the day, are often of great 
value in checking the bleeding. The following will prove service- 
able: Aconite. Active congestion ; throbbing ; local heat. — 
Arsenicum. Urine dark, decomposed, contains coagula. Burn- 
ing pain in kidneys and bladder. In the course of debilitating, 
infectious or malignant diseases, with restlessness, anguish, 
cachexia, and characteristic constitutional indications. (Arsen- 
icum hydrogenisatum is said to be especially useful in the renal 
haemorrhage of Bright's disease.) — Cantharides. Inflamma- 
tion along the urinary tract. Constant and ineffectual desire 
to urinate; urine is voided drop by drop, with burning, cutting 
pain and great urging. Intense burning when voiding urine, 
with tenesmus continuing for some time afterwards. Haemor- 
rhage rarely copious. Urine contains mucous sediment. Hsema- 
turia from stone, with violent pains in the back, along the 
ureters into the bladder. — Chimaphila. In gonorrhoea of 
long standing. Burning, pricking pain while urinating. Copi- 
ous ropy mucous sediment. — Crotalus and Lachesis in low 
fevers and profoundly cachectic states, characterized by degen- 
eration of the blood (Lachesis: like charred straw). — Ipecac- 
uanha. Constant faintness, nausea, prostration ; bleeding is 
profuse. — Lycopodium. In tedious cases ; gravel or chronic ca- 
tarrh; urine scanty, dark-red, with sandy sediment. — Mille- 
folium. Chilliness ; must lie down ; severe pain in the region 
of the kidneys. "The blood forms a sediment in the vessel like 
a bloody cake" (Raue). — Phosphorus. In low fevers. — Se- 
cale. Painless discharge of black blood ; the result of kidney- 
disease ; passive haemorrhage of thin blood ; blood deteriorated ; 
feels cold all over, but objects to being covered; low fever; 
great prostration. — Terebinthina. Acts upon the kidneys as 
Cantharides acts upon the bladder. Burning, drawing pain 
in the region of the kidney^ ; urging and pressure in the blad- 
der, extending upward toward the umbilicus and into the kid- 
neys. Urine thoroughly mixed with blood ; dirty, reddish- 



1196 DISEASES OF THE KIDNEYS AND BLADDER. 

brown or blackish. Coffee-ground sediment in the urine. In 
scorbutic conditions ; in persons who have lived long in damp 
dwellings. 

Consult also Calcarea, Camphora, Colchicum, Eouiise- 
tum, Erigeron, Mercury, Nitric acid, Sulphuric acid, Uva 
ursi. 

Hemoglobinuria. — A condition of the urine characterized by 
the presence of the coloring matter of the blood, few, if any, 
corpuscles being present. The coloring is due to the presence 
of methasmoglobin ; if present in small quantity, it gives to the 
urine a smoky color; if in large amount, the urine appears 
red, brownish-red, or blackish. The urine may contain albu- 
min and sometimes haematoporphyrine ; if the latter, it gives 
to the secretion the odor of fresh meat. The essential feature 
is a separation of the coloring matter of the blood from the 
blood corpuscles. This occurs in severe infectious diseases 
(especially in scarlet fever, erysipelas, typhoid fever, malaria) 
or in poisoning with carbolic acid, naphthol, corrosive subli- 
mate, potassium chlorate, arsenuretted hydrogen, pyrogallic 
acid, and mush-rooms. It may also result from the introduc- 
tion into the veins of foreign blood or serum or from a burn. 
It occasionally occurs as a disease among new-born infants, 
even in epidemic form. The diagnosis rests upon the presence 
in the urine of blood pigment and the absence of blood corpus- 
cles. 

Paroxysmal hemoglobinuria, i.e. hemoglobinuria occurring 
in distinct paroxysms of varying duration, from a few hours 
to a day, or two, is seen usually in male adults, especially in 
those suffering from syphilitic or malarial poisoning. The par- 
oxj^sms are usually excited by mental or bodily exhaustion, ex- 
posure, or getting hands or feet wet. They are preceded by 
chill and fever, the temperature rising to 103° or 104°; excep- 
tionally the temperature is subnormal. There may be vomiting 
and diarrhoea. The patient experiences pain in the back and 
hips, sometimes with a sense of constriction in the chest and 
with labored respiration. The urine has the characteristics al- 
read} r described, and may be albuminous on the start and after 
the attack of haemoglobinuria has passed off. There may be 
general pallor of the skin, with blueness of the finger-tips, 
jaundice, urticaria, or circumscribed oedema. The attack fre- 



ANOMALIES OF THE URINE. 1197 

quently yields with copious sweating, and is likely to be fol- 
lowed by exhaustion. The affection is chronic, not fatal, and 
may disappear without treatment. 

Treatment of hemoglobinuria is unsatisfactory. External 
warmth is both grateful and helpful to the patient. Chrosteck 
claims that amyl nitrite occasionally aborts or prevents an 
attack. 

Albuminuria. — As the term is here used, it refers to the pres- 
ence of serum-albumin in the urine. Whether, or not, such a 
condition must always be considered a pathological state is as 
yet an open question, for while in health only water and salt 
should escape from the blood, it is well-known that albumin in 
varying amounts may be present in the urine of persons who 
are in good health ; hence the recognition of so-called physio- 
logical or functional albuminuria. This is commonly observed 
in young persons, especially in boys, particularly when they 
are rather anaemic, languid, poorly nourished, and of a neu- 
rotic tendency. In such cases albumin may appear in the urine 
and disappear at certain hours of the day. The amount varies ; 
it usually is small, is likely to be increased from exertion of 
any kind and after eating, and disappears when resting. Such 
cases may wholly recover in the course of time, or they con- 
tinue indefinitely, with more or less disturbance of the general 
health and evidence, finally, of a pathological condition. In 
other cases, including adults, albuminous urine is seen regu- 
larly after a meal, especially when the food is rich in albu- 
minous substances (egg, cheese, pastry, etc.); violent pro- 
longed exertion may have the same effect. Again, albumi- 
nous urine may be of daily occurrence when there is neither 
appreciable cause nor failure of health. The albuminuria of 
pregnant women may also be considered physiological. 

It is evident that in many instances extreme care must be ex- 
ercised in properly estimating the importance and meaning of 
this condition. This applies particularly to examinations for 
life insurance ; here the responsibility of the medical examiner 
is very great, since he may injure the company by recommend- 
ing the acceptance of a poor risk or do serious harm to an ap- 
plicant by attaching undue importance to a condition which is 
but transitory. The terms dietetic, cyclic, paroxysmal and 
intermittent albuminuria explain themselves. 



1198 DISEASES OF THE KIDNEYS AND BLADDER. 

Albuminuria is present in febrile conditions, in diseases char- 
acterized by changes in the blood (scurvy, purpura, etc.), in 
chronic poisoning with lead or mercury, in anaemic states, 
syphilis, and in various affections involving the nervous sys- 
tem, as epilepsy, apoplexy, tetanus, delirium tremens, injuries 
to the head ; it is also associated with exophthalmic goitre. 
The most serious form, however, is the albuminuria of renal dis- 
ease, whether this be a mere congestion of the kidneys or acute 
and chronic Bright's disease, suppurative nephritis or degener- 
ative disease of the organ. 

Albumin may also find its way into the urine as the result of 
conditions in which the kidneys are not at fault. Thus, albu- 
minous urine may be due to the formation of pus anywhere in 
the urinary tract, or to the presence of blood, lymph, semen or 
fragments of tumors. In renal albuminuria the albumin is 
evenly distributed throughout the urine, and casts and renal 
epithelium are present ; in other forms the percentage of albu- 
min is frequently much higher at the bottom than at the top of 
the vessel, and is in direct proportion to the amount of pus, 
etc., present; microscopic examination shows the blood, pus 
corpuscles and other sources of albumin. Both forms may 
occur in the same patient. 

Tests for Albumin.— Clifford Mitchell (Manual of Urinary 
Analysis) gives the following directions: Acetic acid test. — 
Filter the freshly voided urine into a tall, narrow test-tube 
through three thicknesses of filter paper, until the tube is three- 
fourths full. Carefully wipe the outside of the tube until it is 
clean and bright. Hold the tube up to the light and see that 
both tube and urine are entirely clear and transparent. Boil the 
upper stratum of the urine in an alcohol lamp flame, inclining 
the tube over the flame so that the latter heats about half an 
inch from the surface of the liquid. Boil thoroughly for thirty 
seconds, removing from the flame whenever the urine threatens 
to boil over, but do not boil the lower half of the urine at all. 
Add three to six drops of a 20 per cent, solution of acetic acid 
to the boiling urine. Shake to and fro gently until acid and 
upper stratum of urine have • thoroughly mixed, then boil 
again, say, for thirty seconds. Hold up the tube against a dark 
background or below a window-sill of a north- window or any 
window where there is no direct sunlight. If albumin is pres- 



ANOMALIES OF THE URINE. 1199 

ent, the upper quarter or third of the contents of the test-tube 
becomes distinctly turbid. If much albumin is present, the 
whole upper third or half of the urine is milky and flocks soon 
begin to fall. If a moderate amount of albumin is present, the 
upper quarter or third is cloudy. If a small amount of albumin 
is present, a more or less distinct turbidity is seen, not percepti- 
ble when the tube is held up to the light. If no albumin is pres- 
ent, the upper, heated and acidulated portion of the urine -will 
resemble the lower in appearance. If the urine be of deficient 
acidity, it will become cloudy when heated from precipitation 
of earthy phosphates. The addition of six drops of acetic 
acid and gentle shaking to and fro will usually dissolve the 
phosphatic cloudiness, and the urine becomes nearly clear whan 
albumin is absent, but more cloudy still when albumin is pres- 
ent. If after boiling a cloudiness appears, which seems to dis- 
appear when acetic acid is added, but after further boiling a 
cloudiness in the upper portion is again plainly seen, a plain 
trace of albumin is present which was not seen at first, owing 
to the phosphatic cloudiness. A ring-shaped coagulum of phos- 
phates remaining half-way down the tube must not be mis- 
taken for albumin. The coagulum of albumin is always in the 
upper part of the tube. Acetic acid must be freely used if 
freshly voided urine is tested, if the urine is strongly alkaline 
and foams upon the addition of the acid ; here acetic acid must 
be added, drop by drop, until the blue litmus paper, dipped in 
the upper quarter of the urine, is turned bright red ; then boil 
again. 

Heller's Test. — The urine is filtered as in the previous test ; if 
not clear, shake the filtered urine with magnesia usta, and 
filter again ; if not yet clear, add to the filtered urine half its 
volume of a ten per cent, solution of caustic potash and boil. 
It becomes cloudy from the precipitation of phosphates. Then 
filter. The filtered urine still being turbid, add to it a few 
drops of magnesian fluid (made by dissolving 1554 grains 
each of pure magnesium sulphate and ammonium chloride in 
twenty-seven fluid ounces of distilled water, -with addition of 
three fluid ounces of ammonia water) and filter again. Then 
pour half-an-inch of pure colorless nitric acid into a test tube, 
hold the tube slightly inclined, and let an equal quantity of 
clear urine trickle down the inside of the tube. The urine floats 



1200 DISEASES OF THE KIDNEYS AND BLADDER. 

on the surface of the acid. If serum albumin is present, a 
sharply defined zone of whitish color will be observed at the 
point of contact between the acid and the urine, becoming 
more or less pronounced according to the amount of albumin 
present. If but little albumin is present, it may be necessary 
to hold the tube against a dark ground to see the zone. If no 
zone is seen, set the tube aside for half an hour, or more. A 
trace of albumin may then be seen which was not visible at 
first. The chief advantages of this test are : it is simple ; it pre- 
cipitates one five-hundredth of one per cent, of albumin ; it pre- 
cipitates various albuminous substances, but not phosphates, 
true peptones, or vegetable alkaloids. The following chances 
for error are present : If the test is carefully and slowly per- 
formed, the albumin appears in a distinct white ring, not in a 
generally diffused zone of haziness. A cloudiness above the 
point of contact, more diffused and spreading downward, is 
not albumin, but due to precipitation of urates, especially in 
urines of high specific gravity-. A light cloudiness near the sur- 
face of the urine is not due to albumin, but to mucin (nucleo- 
albumin). In all urines a transparent zone of color appears, 
violet, reddish or brown ; this is not due to albumin, but to oxi- 
dation of the normal chromogens of the urine. Crystals of 
urea form if the urine contains three per cent., or more, of urea. 
A yellowish-white zone may be due to the precipitation of cer- 
tain resinous bodies (cubebs, turpentine, copaiba, 'etc.) taken 
by the patient. If the mixture of urine and acid be shaken 
with alcohol, the resins will be dissolved without effecting the 
coagulated albumin. If blood is present, the albumin-ring will 
be colored brown-red ; if bile, greenish or blue. If the nitric 
acid contains nitrous acid, bubbles will arise, even in acid 
urine, and may obscure the ring ; if the urine is alkaline, bubbles 
will alwaj^s be seen, even if the nitric acid is pure. 

Heat and Nitric Acid Test. — Boil the clear urine in a test 
tube, and add one-tenth of its volume of nitric acid ; the pres- 
ence of albumin is shown by cloudiness, coagulum or precipita- 
tion. Cloudiness ma}' be due to phosphates; these are dis- 
solved on the addition of an acid. Persistence of the cloudi- 
ness indicates albumin. 

Picric Acid Test. — Make a saturated solution of picric acid, 
six or seven grains to the ounce of boiling distilled water. 



ANOMALIES OF THE URINE. 1201 

Float two inches of the reagent on a column of urine four 
inches deep. As far as the yellow color extends the coagulated 
albumin renders the mixture turbid, forming a contrast with 
the clear urine below. Albumin, peptone, mucin, urates, al- 
buminose, kreatinine, vegetable alkaloids and piperazine are 
all precipitated, but are dissolved by moderate heat. 

For other tests see special works on urinary analysis. 

Prognosis. — The prognosis of albuminuria must rest upon 
repeated and accurate tests and a knowledge of the source and 
cause of the disturbance. In addition to what has already 
been said, the necessity of great caution in diagnosis and prog- 
nosis may be still further emphasized. It is evident that tran- 
sient or intermittent albuminuria is much less serious than 
when persistent. The appearance of albumin in the urine, espe- 
cially with casts, in a man in the prime of life, say, at forty 
years of age, is always serious. The tendency to renal albumi- 
nuria increases with advancing years. 

Pyuria. — Pus in the urine occurs in pyelitis, pyelonephritis, 
tuberculosis or abscess of the kidneys, cystitis, urethritis, some- 
times in leucorrhcea, and from rupture of an abscess (perine- 
phric, peritonitic, or on the abdominal wall) into any portion 
of the urinary passage. Its presence in the urine always gives 
rise to albuminuria. The urine is yellowish- white or white, 
and generally of alkaline reaction and of ammoniacal odor. 
The sediment is gray, heavy, tenacious, ropy ; casually exam- 
ined, it resembles that of phosphates, but is whiter and not so 
dense. The supernatant fluid is turbid. The presence of pus- 
corpuscles and epithelium from the renal pelvis and the bladder 
is easily detected under the microscope. The treatment of 
pyuria is that of the primary disease. 

Chyluria or Galacturia is due to the flow of lymph into the 
urinary tract. The urine appears white and homogeneous, 
like milk ; sometimes the presence of blood gives to it a pink 
color. Exposed to the air, a creamy layer, sometimes a firm 
mass like jelly, may form at the bottom of the vessel. Made 
alkaline, and then shaken with ether, the fat is dissolved and 
the urine appears clear. It usually is more or less albuminous 
and under the microscope shows molecular fat, oil globules, 
leucocytes, and occasionally red blood corpuscles. The disease 
is not infrequent in the tropics, where it is thought of parasitic 
76 



1202 DISEASES OF THE KIDNEYS AND BLADDER. 

origin, i. e. due to the presence, in the lymph vessels, of the 
filaria sanguinis hominis ; in the temperate zone it is rare, 
probably non-parasitic, and without special danger. 

Lipuria or Adiposuria are terms used to describe the presence 
of fat in the urine (lipaciduria : presence of volatile fatty acids, 
as acetic or butyric acid, in the urine). The fat enters the 
urinary tract directly (as in fatty degeneration of renal epithe- 
lium, inflammatory destruction of perinephric fat-tissue, pus in 
pyonephresis, etc.) or is wholly or in part eliminated by the 
blood (poisoning with phosphorus, chronic alcoholism, 
phthisis, etc.). The excessive use of fat in the food (as when 
taking cod-liver oil for medicinal purposes) or fat-embolism 
after fractures, diabetes and cancer of the pancreas are other 
conditions in which lipuria exists. The fat occurs in greatly 
varying amounts. It may require microscopic examination to 
detect the oil globules or they may be sufficiently abundant to 
be seen with the naked eye ; again, there may be so much fat 
present that upon cooling of the urine it forms a mass resem- 
bling lard or tallow. Abundant lipuria suggests serious 
disease of the kidneys or cancer of the pancreas. 

Lithuria. — Deposits of uric acid or urates, chiefly sodium, 
potassium and ammonium urates, occur frequently in persons 
enjoying good health ; it is a common feature of inflammatory 
affections (pneumonia, rheumatic fever, etc.), especially when 
characterized b} r profuse sweating ; it is persistent in gout and 
is closely associated with lithaemia or the so-called uric acid 
diathesis. It is seen in crystals or in amorphous masses when 
the urine has cooled in the chamber ; the former macroscopic- 
ally resemble sand or Caj^enne pepper; the latter, fine brick- 
dust. The coloring is due to the presence of urinary pigments. 
It must be remembered that the presence of this sediment does 
not necessarily indicate excessive excretion, but simply condi- 
tions which favor ready deposition of the urates or uric acid. 

A clear definition of what constitutes lithamiia or uric acid 
diathesis is not yet possible. Murchison's teaching that func- 
tional disturbance of the liver is the primary and chief cause is 
far from proved or accepted. It is thought probable that de- 
fective tissue or food metabolism, particular^ in the nitrog- 
enous elements, which may be closely connected with deficient 
oxidation and which is oftenest seen in large eaters and drink- 



ANOMALIES OF THE URINE. 1203 

ers of lazy habits, gradually leads to the changes which are 
comprised under the term gout. Haig (1896) expresses his 
belief that uric acid is a cause of high arterial tension, head- 
ache, epilepsy, mental depression, paroxysmal hemoglobinuria, 
anasmia, Bright's disease, diabetes, gout and rheumatism. 

Oxaluria. — Oxalic acid occurs in the urine in combination 
with lime, forming oxalate of lime, and held in solution by the 
sodium dihydric phosphate. It is present in acid urine, and 
may be detected as octahedral or dumb-bell shaped crystals in 
urinary mucus or adhering to the sides of the vessel. The 
amount depends greatly upon the diet ; thus it is largely in- 
creased after eating freely of tomatoes and rhubarb. It may 
alternate with urates or uric acid in the urine. The constant 
presence of oxalates is thought to be associated with a diathe- 
sis of which nervous dyspepsia, nervous irritability, mental 
and bodily depression, with a pronounced tendency to melan- 
cholia, are the constitutional symptoms ; these are usually 
relieved by the administration, three times daily, of from five 
to seven drops of fresh nitrohydrochloric acid, aided by the ex- 
clusion of sweets and indigestibles from the patient's dietary. 
Oxalates, when in excess, may be deposited before the urine 
can carry them off, in which case a calculus is formed. Oxa- 
luria also occurs in connection with gout, lithaemia, spermator- 
rhoea, diabetes. The chemical tests are somewhat complicated 
and belong to the laboratory. 

Cystinuria. — Cystine, under the microscope, appears in hex- 
agonal plates. The cause of its presence in the urine is not 
positively known. It occurs constantly and in varying quan- 
tity. It may form a smooth, yellow, translucent calculus, of 
crystalline fracture. 

Phosphaturia. — Phosphoric acid in the urine invariably oc- 
curs in combination with bases, in the form of phosphates, 
some of which are always held in solution, never being found 
in the sediment, while others, under favorable conditions, ap- 
pear in the sediment. The term alkaline phosphates is applied 
to those which are never found in the sediment ; they are the 
phosphates of sodium and potassium. The phosphates which 
under certain conditions may occur in the sediment are called 
the earthy phosphates ; they are the phosphates of calcium and 
magnesium. When the urine is acid, all these phosphates are 



1204 DISEASES OF THE KIDNEYS AND BLADDER. 

held in solution ; when the urine is feebly acid, neutral or alka- 
line, the eartlry phophates appear in the sediment. The triple 
phosphates (ammonio-magnesium phosphate) is a product of 
decomposition of urine, resulting from the introduction of a 
bacterial ferment, as in cystitis, the ammonium carbonate of 
the urea uniting with the magnesium phosphate of the urine. 
Under the microscope the earthy phosphates consist of minute, 
pale granules in irregular patches ; the triple phosphates ap- 
pear as "fern-leaf" crystals. The free deposit of earthy 
phosphates does not prove an excess of phosphoric acid in the 
urine ; this can only be determined accurately b} r carefully 
made chemical tests. The amount of phosphates is increased 
in wasting diseases, in meningitis, and in epileptic convulsions. 
The phosphatic diabetes of Tessier is characterized b3^ increased 
excretion of phosphates, polyuria, thirst, emaciation, loss of 
flesh, and strength. Excessive excretion of phosphates occurs 
in some cases of neurasthenia ; it is diminished in acute dis- 
eases and during pregnancy. Persistent alkalinity of urine and 
subsequent abundant deposit of earthy phosphates is a com- 
mon feature of indigestion, especially when there is a deficiency 
of Irydrochloric acid. The formation of phosphatic calculi is 
sought to be averted by the internal administration of boric 
and benzoic acid, with the view of thus rendering the urine 
acid and of enabling it to retain in solution the earthy phos- 
phates present. A sediment of earthy phosphates disappears at 
once as soon as the urine is rendered distinctly acid. 

Urobilinuria. — The presence of an abnormal amount of uro- 
bilin in the urine is indicated by a dark-red or brown color of 
the urine and by the formation of a yellow foam when shaken. 
It occurs in connection with internal haemorrhage from the 
absorption of extravasated blood and in fevers and certain 
diseases of the liver. The presence of bilirubin and indican in 
high-colored urine suggests the probable presence of urobilin. 

Indicanuria. — An excess of indican (indoxyl-sulphuric acid) in 
the urine indicates chiefh T increased putrefaction of albumin in 
the intestine ; it is therefore found in conditions where there is 
deficiency or absence of hydrochloric acid, in gastritis, cancer 
or ulcer of the stomach, in diseases which cause impediment in 
the peristaltic movements of the small intestines, as ileus and 
peritonitis; in diseases characterized by albuminous putrefaction 



ANOMALIES OF THE URINE. 1205 

in some part of the body, as pleurisy with copious unhealthy 
exudation, fetid bronchitis, empyema, pulmonary gangrene, 
peritonitis with formation of putrid pus, etc., in cholera, Ad- 
dison's disease, chronic phthisis, cancer of the liver, dysentery, 
typhoid fever, chronic suppurations, and certain diseases of the 
nervous system ; also after the use of turpentine, nux vomica, 
creosote, oil of bitter almonds. The most convenient test is 
that of Jaffe: "Mix 10 cubic centimetres of strong hydro- 
chloric acid with an equal volume of urine in the test-tube, and 
while shaking add drop by drop a perfectly -fresh saturated 
solution of chloride of lime, or chlorine-water, until the deepest 
attainable blue color is reached. The mixture should next be 
agitated with chloroform, which readily takes up the indigo 
and holds it in solution, and the quantity present may be ap- 
proximately estimated according to the depth of the color. 

If the urine contain albumin, it should be removed before ap- 
plying these tests, otherwise the blue color often arising from 
the mixture of hydrochloric acid and albumin after standing 
may prove misleading." (Purdy.) 

Melanuria. — Melanin may be present in urine either in solu- 
tion or as a granular deposit. The urine, if normal when 
voided, on exposure gradually becomes dark and finally black ; 
the urine may be dark when first passed. It is present usually, 
but not always, in melanotic tumors, and occurs also in 
malarial, wasting and inflammatory conditions. The discol- 
oration of the urine becomes intensified upon the addition of 
sulphuric or hydrochloric acid. The addition of a few drops of 
a strong solution of perchloride of iron causes the appearance 
of a gray color "which is imparted to the precipitate of phos- 
phates occurring at the time if more of the reagent be added, 
and which dissolves again in an excess " (Mitchell). 

Acetonuria. — An excess of acetone in the urine is usually due 
to increased albuminous decomposition. It is found in tedious 
febrile affections, diabetes, some forms of cancer, in psychoses, 
inanition, and as the result of auto-intoxication. Its charac- 
teristic chloroform and acetic acid odor may be marked in 
both the patient's breath and urine, especially so in diabetic 
coma, in the gastric crises of diabetes, particularly in cases 
which were serious from the beginning, and in febrile affections' 
of children. For tests consult special works. 



1206 DISEASES OF THE KIDNEYS AND BLADDER. 

Diaceturia (Diaceticaciduria) . — Diacetic acid is found in dia- 
betes, in some fevers, in wasting affections, and in infantile 
convulsions. Its presence in children appears to be of trifling 
importance, but in adults it is closely associated with ap- 
proaching fatal termination, characterized b}- coma. Its rela- 
tion to diabetic coma is especially striking, as shown by 
Jaksch, Mitchell, and others. A form of diaceturia, due to 
auto-intoxication, has been described (diacetasmia) character- 
ized by vomiting, dyspnoea, jactitations and, in adults, coma 
and death, without other discoverable lesion. Mitchell gives 
the following test : To a few c.c. of urine add a strong solution 
of perchloride of iron, drop by drop, until the precipitation of 
phosphates ceases. This may be readily observed by letting the 
precipitate settle, after a few drops of the iron solution have 
been added, which it will do in about ten minutes. Filter, and 
to the filtered urine add more of the iron solution. If now a 
Bordeaux-red color is seen, another portion of the urine is 
boiled and similarly treated, and if this second sample give no 
reaction, suspect presence of diacetic acid. Confirm b\ r treat- 
ing a third portion of the urine with sulphuric acid, shake the 
mixture with ether, and draw off the ether. Test the ethereal 
extract with the iron solution as above, and if the Bordeaux- 
red color be obtained, which disappears on standing for 
twenty-four to forty-eight hours, diacetic acid is present, espe- 
cially if acetone can be detected in the distillate. 

Alkaptonuria consists of the presence of alkaptone in the 
urine, and, in a broader sense, of aromatic compounds. Alkap- 
tone is an amorphous, brownish or yellow nitrogenous sub- 
stance, first described by Boedecker. When treated with cold 
liquor potassae it strikes a dark-brown color, the coloration 
preceding from the surface of the liquid downward. Urine con- 
taining it may be clear, but darkens on exposure. It has been 
found in the healthy and in those suffering from tubercular dis- 
ease. All the aromatic substances may be mistaken for sugar, 
since they reduce Fehling's solution. They possess no special 
clinical significance. 

Chyluria and Glycosuria have been considered elsewhere. 

Casts. — To determine the presence of casts, urine should be 
allowed to stand for a few hours in a conical glass vessel. It 
is well to prevent rapid growth of bacteria in the urine by add- 



1 



UREMIA. 1207 

ing to it thymol or some similar substance. The clinical signi- 
ficance of casts is great, for their presence not only indicates 
renal disease, but often much light is thrown upon the nature 
of the affection by the character of the casts found. Thus, 
hyaline casts, although not necessarily proving fixed renal dis- 
ease, and at times absent in albuminuria, usually indicate 
albuminuria; they may also be present in cholera, jaundice, 
and in poisoning with alcohol and sulphuric acid. Blood casts 
warrant the presumption of renal haemorrhage. Epithelial 
casts indicate that desquamation of the renal epithelium has 
taken place. White blood corpuscles are proof of the migra- 
tion of these important constituents from the vessels. Fatty 
granular cells and fat drops result from fatty degeneration in 
the kidneys, and are significant in diffuse or chronic parenchy- 
matous nephritis. 

Hyaline casts are probably formed from coagulated albumin 
which has been eliminated from the kidneys. They are homo- 
geneous, colorless, clear and glassy, soft, narrow and long, and 
sometimes broken off at one end, frequently straight, more 
often curved. They stain easily with carmine or gentian- 
violet; are dissolved by heat; resistant to acids. They fre- 
quently are covered with deposits of granular matter, blood 
corpuscles, etc., which have become attached to them. Blood 
casts sometimes consist of pure coagulated blood, making a 
perfect cast of the uriniferous tubule in which they were formed ; 
oftener they consist of hyaline casts to which red blood cor- 
puscles are densely adhering. Granular casts consist of hyaline 
casts covered with granular masses, or of coagulated masses 
of albumin, or of granules of haematoidin. The term fatty casts 
is used when the granules are large enough to be readily recog- 
nized as fat. They may be held within the adherent cells or 
constitute irregular globules of fat. Epithelial casts consist of 
pure renal epithelium or of hyaline casts to which epithelium 
has attached itself. Evidence of atrophy or fatty degeneration 
may be presented by them. They resemble swollen -white cor- 
puscles. Waxy casts are found in acute and subacute nephritis 
and in amyloid kidney; they are broad, yellowish, opaque, 
glistening. 

UREMIA. 

A toxaemia, chiefly affecting the nervous system, which oc- 



1208 DISEASES OF THE KIDNEYS AND BLADDER. 

curs in the course of Bright's disease and is the result of pro- 
longed interference with the secretion of urine, depending upon 
renal disease, or of obstruction to the outflow of urine. While 
the degree of poisoning may be said to correspond to the reduc- 
tion in the quantity of urine voided, the essential feature is the 
retention of the urinary solids; thus, profound uraemia may 
develop when large quantities of urine are passed which is 
simply water, as is the case in renal cirrhosis. On the other 
hand, there may be prolonged diminution or actual suppres- 
sion of urine without symptoms of uraemic poisoning, in which 
case it is reasonable to assume that vicarious elimination is 
taking place through the bowels or through the skin, or that 
the patient lacks in susceptibility to the action of the retained 
poisonous substances. Uraemia may also occur from impediment 
of the renal circulation or from extreme engorgement of the 
renal vessels due to compression, or in profound alterations of 
the blood. While of especial interest in connection with renal 
diseases, it ma}- also be associated with cholera, angina pec- 
toris, chronic endarteritis and pulmonary emphysema. 

As yet, the specific cause of the symptoms produced is not 
clearly understood. There is no longer good reason to pre- 
sume that uraemia is essentially uric acid poisoning, nor has it 
been satisfactorily demonstrated that the symptoms are 
caused, as was claimed by Frerichs, by the presence of carbon- 
ate of ammonia. Neither do the facts sustain Traube's theory 
that an acute localized oedema of the brain is the cause of the 
uraemic symptoms ; it is noticeable that such an oedema, 
though at times present, is by no means a constant lesion and 
fails to explain many important and characteristic symptoms 
of uraemia. We must therefore be content to attach the respon- 
sibility to the retention of poisonous materials which should 
have been eliminated. 

Symptoms. — The symptoms of uraemia present a large range 
as to intensity, rapid^ of development, or immediate serious- 
ness ; hence the natural division into acute and chronic uraemia. 

The milder forms are characterized by indisposition, disturb- 
ances of digestion, — as nausea, eructations, vomiting and diar- 
rhoea, — headache, tendency to stupor, uneasiness, and occasion- 
ally slight twitching of muscles, especially of the face and ex- 
tremities. Such cases ma}' continue for a long time, with im- 



UREMIA. 1209 

provement finally, or may suddenly give way to more violent 
and threatening manifestations. The most striking symptoms 
are those experienced in the nervous system, and of these the 
most prominent is con vulsions. These may be preceded by gener- 
al malaise, restlessness and pain in the head, or they may come 
on abruptly. They bear a striking resemblance to the convul- 
sions of epilepsy; even the epileptic "cry" may be present. In 
the majority of cases the convulsions rapidly succeed each other, 
the patient remaining unconscious during the intervals. 
Rarely single seizures are seen, usually beginning with contrac- 
tions in one of the extremities, oftener the arm, rapidly invad- 
ing the trunk, face and legs, with exaggeration of the convul- 
sive action in one-half of the body. Again, the severe convul- 
sive seizures may alternate with comparatively light attacks. 
Localized or Jacksonian epilepsy has been noted. During these 
attacks the temperature may be elevated to 104° or 106°, but 
oftener it is lowered, and after the attack it may rapidly drop 
to 95°, and even lower. Uraemic amaurosis is of frequent oc- 
currence in such cases, although it may also be seen when there 
are no convulsions. It develops rapidly, the reaction of the 
pupils to light is rarely lost, there are no ophthalmoscopic 
changes, and it disappears after a few days. Deafness, also 
due to central causes, is not unusual, and in the majority of 
cases occurs in connection with stubborn headaches and other 
expressions of disturbance in the nervous system. There may 
be coma with or without convulsions. It may be associated 
with muscular twitchings, especially of the face and hands, and 
be preceded by dulness, stupidity, and constant headache, or 
appear without warning or suspicion of renal disease. In some 
cases a condition of profound general torpor persists for a long 
time, sometimes for many weeks, with furred tongue and foul 
breath. Mania, usually of a restless, subdued, talkative char- 
acter, sometimes appears unexpectedly in persons seemingly in 
usual good health ; delusions, more often of persecution, are 
occasionally seen. A strongly marked tendency to melancholy 
characterizes these cases. Other nervous symptoms are : head- 
ache, frequently occipital and extending into the neck, accom- 
panied with dizziness, numbness and tingling in the fingers, 
cramps in the muscles of legs, particularly at night, annoying 
itching of the skin, and occasionally erythema. Of these, the 



1210 DISEASES OF THE KIDNEYS AND BLADDER. 

headache is especially persistent. Local paralyses (hemiplegia 
or monoplegia) are rare; they may occur in chronic cases of 
Bright's disease or follow a convulsive seizure. They do not 
essentially differ from the paralysis of organic lesion of the 
brain, and are associated with localized or diffuse cerebral 
oedema. 

Gastro-intestinal symptoms of uraemic poisoning consist of 
vomiting and diarrhoea, sometimes the former alone. The 
vomiting is uncontrollable and evidently of cerebral origin ; in 
some cases, however, there appears to be much irritation of 
the gastric mucous membrane from the presence of urea and 
carbonate of ammonia, which are readily detected in the 
vomitus. Diarrhoea may exist without vomiting ; it may be 
associated with expressions of intense catarrhal, even diph- 
theritic, inflammation, with tenesmus and bloody stools ; the 
stools also may contain urea and carbonate of ammonia, the 
result of an attempt at the elimination of poisonous material. 
The skin, especially on the face, particularly- on the side of the 
nose, may show of this effort at elimination of urea. Schot- 
tin and later observers have found scales of urea coating the 
skin after the evaporation of the sweat in cholera patients. A 
uraemic stomatitis has been described, involving the mucosa of 
the lips, gums and tongue, with difficult, painful mastication 
and swallowing, copious flow of saliva, foulness of taste, and 
heavy, fetid breath. Dyspnoea is present in some cases. It is 
usually nocturnal, sometimes continuous, again occurring in 
paroxysms with noisy, stridulous breathing, closely resem- 
bling attacks of true asthma. Cheyne-Stokes breathing occurs 
with comparative frequency-, even when there is no coma. In 
some instances this condition proves very stubborn, but recov- 
ery may take place. The pulse usually is slow, but becomes 
small and frequent with the appearance of convulsions ; it is 
always hard and tense. Some writers describe a "uraemic 
chill" which appears suddenly with other symiptoms of 
uraemic poisoning, with a great rise in temperature, followed 
by a corresponding fall. 

Diagnosis. — The diagnosis rests upon the result of urinary 
examination. Cerebral haemorrhage or tumors, meningitis, 
alcoholic intoxication, opium poisoning, infectious fevers, and 
other morbid conditions, may-, and at times do, so closely 



ACUTE BRIGHT'S DISEASE. 1211 

resemble uraemia as to render differentiation extremely diffi- 
cult. Hence the necessity of frequently repeated and carefully 
conducted tests of the urine, even though there may be no his- 
tory of diminution or suppression of urine ; in the presence of 
oliguria or anuria the omission of this simple procedure would 
be inexcusable. For treatment see Acute and Chronic Bright's 
disease. 

ACUTE BRIGHT'S DISEASE. 

An acute diffuse inflammation of the kidneys, affecting the 
epithelial, vascular or intertubular structure, presenting a 
varied symptomatology and a large range of pathological 
changes. The following terms represent attempts to distin- 
guish types of the disease: acute nephritis; acute catarrhal 
nephritis ; acute diffuse nephritis ; acute desquamative nephritis ; 
acute parenchymatous nephritis ; acute croupous nephritis ; 
acute exudative nephritis ; glomerular nephritis ; glomerulo- 
capsular nephritis. 

./Etiology. — Acute Bright's disease may occur from exposure 
to cold ; it is thought that this is particularly dangerous when 
taking place after a prolonged debauch. In many cases the 
responsible cause is the presence of some infectious material 
which reaches the kidneys through the circulation, and in the 
attempt at elimination is afforded the opportunity of exerting 
its specific action upon the renal parenchyma, the damage 
there effected depending largely upon the amount of poison 
introduced, the intensity of its action, the duration of its influ- 
ence, the susceptibility and resisting power of the individual 
attacked, and the previous state of the kidneys. It is on this 
account that the clinical history of this affection, its duration 
and termination are so varied. Of the infectious diseases in the 
course of which renal complications occur as a special localiza- 
tion of the specific poison present, scarlet fever heads the list ; 
nephritis here rarely shows itself at the beginning, but is fre- 
quent toward the end of the third week. Nephritis is common 
also in small-pox, especially of the haemorrhagic type, and 
may be associated with measles, cholera, yellow fever, diph- 
theria, cerebro-spinal meningitis, erysipelas ; it is less frequent 
in dysentery, chicken-pox, acute tuberculosis, septicaemia, 
syphilis, malaria, acute pneumonia, acute articular rheuma- 



1212 DISEASES OF THE KIDNEYS AND BLADDER. 

tism. It may result from poisoning with turpentine, canthar- 
ides, potash (especially chlorate, chromate and nitrate), car- 
bolic acid, oxalic acid, mineral acids, phosphorus, arsenicum, 
corrosive sublimate. It may complicate pregnane}- ; the ques- 
tion is still open whether in such cases the mischief arises from 
the presence of some special poison or from compression of the 
renal veins. It is more frequent in primiparas, and usually 
appears during the latter months of pregnancy. Acute neph- 
ritis may result from extensive burns and occasionally is asso- 
ciated with diseases of the skin, as acute pemphigus, pustular 
eczema and various chronic eruptions. 

Morbid Anatomy. — In the milder forms the renal epithelium 
alone is affected. Examined with the unaided eye, the changes 
seen are trifling. They consist chiefly of moderate swelling 
and, on section, of a dim reddish-gray appearance of the struct- 
ures when there is merely cloudy swelling, but grayish-white 
or yellow in case of fatty degeneration. Under the microscope 
the following epithelial changes are observed : Cloudy swelling. 
The cells are swollen, their contents granular and cloudy ; the 
nuclei swell and eventually disappear. The epithelium of the 
cortical tubules shows these changes most decidedly, but thej^ 
are present also in that of the glomeruli. It occurs commonly 
in the lighter form of nephritis found in connection with the 
acute infectious diseases. Fatty degeneration succeeds the 
stage of cloudy swelling or comes on independently. Fat- 
drops are seen in the cells of the uriniferous tubules and in the 
epithelium of the glomeruli ; the tendency is to disintegration 
of the cells. Fatty degeneration occurs in acute infectious dis- 
eases and from the action of certain poisons, like phosphorus ; 
also in anaemic conditions.— Necrosis. The nuclei of the cells 
disappear, and the cells themselves become large, clear, homo- 
geneous flakes. Necrosis of the epithelium is found in acute 
infectious diseases and as the result of toxic action of poisons, 
like cantharides. All these changes may be found in the same 
kidney, at the same time, varying in degree. Restoration of 
the affected structures may take place, proceeding from such 
portions of it as have remained normal, but the tendency is to 
cell destruction and disintegration. In true nephritis these 
epithelial changes are present in an exaggerated form, with a 
strong tendency to desquamation, and there is, as its essential 



ACUTE BRIGHT'S DISEASE. 1213 

feature, involvement of the interstitial tissue and of the vessels, 
with escape of fluid and cells from the wall of the vessels. Dila- 
tation and swelling follow the exudation and coagulation in 
the interstitial connective tissue of the inflammatory fibrinous 
exudate. White corpuscles abound in the interstitial tissue 
and may be found within the uriniferous tubules. Hyaline 
casts prevail in large numbers. The vessels themselves are 
congested or compressed from the presence of copious inflam- 
matory exudate. Haemorrhagic effusion is common into the 
interstitial tissue, within the uriniferous tubules, or into the 
capsules of Malpighi. These changes may be localized or 
diffuse, and they determine the microscopic appearance of the 
parts. Thus, the kidney is large in proportion to the amount 
of the exudate; it is soft to the feel when there is considerable in- 
flammatory oedema ; it is red when hyperemia is pronounced ; 
pale, when there is marked anaemia; yellowish-gray , when there 
is fatty degeneration. On section, there is seen dilatation of 
the medullary substance; striation is obscured or largely 
obliterated. Spots, here of hyperaemia, there of fatty degener- 
ation, elsewhere of anaemia, give to the kidney a mottled ap- 
pearance. 

The so-called glomerulonephritis, as frequently seen in scar- 
let fever, is characterized by degeneration and desquamation of 
the epithelium in the glomeruli only, with a condition of the 
vessels presenting the characteristic swelling and homogeneous 
change known as "hyaline." 

Symptoms. — The onset of acute nephritis may be sudden, 
especially in cases arising from exposure to cold, and then 
dropsy may appear within a short time. When arising in the 
course of infectious fevers, its onset is more insidious, so that 
its existence, in many cases, is not even suspected ; hence the 
necessity of frequent examinations of the urine in diseases likely 
to be complicated by nephritis. In some instances chilliness or 
rigors are the first symptoms noted ; in children convulsions 
may mark the beginning ; in others there is general malaise, 
with nausea and vomiting, moderate rise in temperature, and 
some puffmess about the face and ankles. 

The urine of approaching nephritis is scanty, high-colored, 
albuminous, bloody, and contains tube-casts. Anuria some- 
times occurs at the very first. In the great majority of cases 



1214- DISEASES OF THE KIDNEYS AND BLADDER. 

the amount of urine passed in twenty-four hours does not ex- 
ceed fifteen to twenty ounces and may amount to only four or 
five ounces in the same length of time. Generally speaking, the 
diminution in the quantity of urine voided is in proportion to 
the severity of the anatomical changes which have taken place 
in the kidney. The presence of blood renders the urine smoky 
in appearance or of a deep porter-color; sometimes, but 
rarely, bright-red. Upon standing, a heayv sediment is depos- 
ited, containing red and white blood corpuscles, renal epithe- 
lium, epithelium from the urinary passages, hyaline casts, uric 
acid crystals, urates, etc. Albumin, in amount varying from 
% to 1, or even 2, per cent., is present in many cases ; this symp- 
tom, however, is fitful and irregular. The urine being acid, al- 
bumin is promptly precipitated upon boiling. The percentage 
of urea is high in any specimen taken, but the total amount for 
the twent}'-four hours is greatly reduced, often to one-sixth of 
the normal amount. The specific gravity is high, 1.025, or 
more. The urine may be voided with a considerable sense of 
uneasiness and burning. Dropsy may set in within a daj r , or 
two, after the first symptoms of acute nephritis have been ob- 
served, or, as is frequent in infectious fevers, especially 
in scarlet fever, when the patient was thought to have entered 
upon convalescence from the fever. Puffiness about the eyes 
and ankles is usually noted first ; this extends to the extrem- 
ities, genitalia, and may invade the pleura and peritonaeum. 
In some cases pulmonary oedema may occur ; oedema of the 
glottis is a rare manifestation. In post-scarlatinal nephritis 
pleural effusions are common and excessive. The general rule 
applies that, the greater the diminution of urine, the more pro- 
nounced the dropsy. Dropsy is a prominent feature of post- 
scarlatinal nephritis, of the nephritis of pregnancy, and of ne- 
phritis from exposure to cold. In febrile cases, as a rule, 
dropsy is neither so prominent nor so serious. In some fevers, 
especially typhoid fever, haematuria and great scantiness of 
urine are frequently present. It must be remembered that even 
severe cases of nephritis may not present dropsy. Uraemia 
may occur at any time. When there is pronounced anuria at 
the very beginning, danger of uraemic poisoning is great, and 
severe symptoms, such as eclampsia, may then set in quite 
early. Usually, symptoms of uraemia develop later and do not 



ACUTE BRIGHT'S DISEASE. 1215 

reach a high degree of intensity. In some instances the per- 
sistent vomiting from which the patient suffers is a manifesta- 
tion of mild uraemia ; the twitching, wakefulness and restless- 
ness of such cases is due to the same cause. Delirium is likely 
to develop later, followed by stupor and coma. Uraemic 
dyspnoea is not uncommon. Such conditions are not rare in 
the nephritis of scarlet fever. Nevertheless, uraemia is the ex- 
ception, and not the rule, in acute nephritis. 

As the disease advances, digestion becomes somewhat de- 
ranged ; there is loss of appetite, heavy coating of the tongue, 
gastric uneasiness, constipation, sometimes diarrhoea. Ema- 
ciation, general exhaustion and anaemia develop, and if the 
tendency of the patient is downward, there is a disposition to 
epistaxis and haemorrhagic effusions beneath the skin. The 
skin assumes marked pallor, appears translucent, and pre- 
serves remarkable dryness, often stubbornly resisting all at- 
tempts to bring on moisture. The pulse usually is hard and 
full, with increased tension, slow at first, rapid later on. An 
existing tendency to cardiac hypertrophy, especially in hearty, 
rugged children, renders it necessary to keep close watch upon 
the condition of the apex beat and the accentuation of the 
aortic second sound. Changes of temperature are not pro- 
nounced ; a moderate fever, with a temperature not exceeding 
101° to 103° is, however, not unusual, particularly in cases 
presumably due to exposure. Haemorrhagic retinitis and, ex- 
ceptionally, papillitis are rare complications. 

The so-called primary idiopathic nephritis, resulting from 
exposure to cold, is in the majority of cases sudden in its onset, 
and usually runs a rather rapid course. Mild cases recover in 
a few weeks, while those of a severer type, with violent neph- 
ritis, often haemorrhagic in tendency, may terminate fatally in 
two or three weeks or, if they recover, get well slowly. 

The nephritis of pregnancy comes on insidiously, with slight 
urinary disturbances, frequent micturition, dropsical swelling 
of the lower extremities, albuminous urine, and occasionally 
nausea and vomiting. Recovery takes place rapidly after the 
birth of the child, or eclampsia, an expression of uraemic poison- 
ing, sets in during labor. The onset of the convulsions may be 
sudden ; they are general, violent, frequently repeated, and fol- 
lowed by coma. The prognosis in such a case is bad for both 



1216 DISEASES OF THE KIDNEYS AND BLADDER. 

mother and child, death of the mother occurring in about one- 
third of all the cases, and death of the child in even a larger 
percentage. 

Diagnosis. — The diagnosis rests upon the results of frequent 
and carefully made examinations of the urine. There may be 
much difficulty in determining whether we deal with an acute 
attack or with an acute exacerbation of a case of long stand- 
ing ; or the physician may be perplexed by the absence of al- 
buminous urine, as occurs in exceptional cases, even with ex- 
tensive dropsy ; in the latter, examination of the urine should 
be made at brief intervals, and is then usually rewarded by the 
appearance of albumin in the urine. 

Prognosis. — The prognosis in the great majority of cases is 
serious. It is most favorable in nephritis due to exposure or 
poisoning, unless the amount of poison injected is large. 
The mortality in young children, especially when associated 
with scarlet fever, and of the nephritis of pregnancy is high, 
about one-third of all the cases proving fatal. As a rule, the 
more prolonged the course, the more guarded must be the 
prognosis, because of the increased danger from complications, 
especially uraemic and cardiac. Favorable symptoms are : in- 
crease in the amount of urine voided ; lessening of the percent- 
age of albumin present ; increase of the percentage of uric acid ; 
lessening of the dropsy, especially disappearance of the dropsy 
by the end of the first month ; satisfactory state of appetite, 
strength, and of the general condition. Unfavorable symptoms 
are : low arterial tension, low percentage of urea in the urine ; 
uraemia ; severe general dropsy ; severe effusions into the serous 
cavities. Especially dangerous complications are: extensive 
hydrothorax and inflammation of the internal organs, as sec- 
ondary pneumonia. If the dropsy persists bej'ond the end of 
the first month, with intense pallor and largely albuminous 
urine, the case promises to become chronic. At best, the course 
of the disease, though recoveries may take place under the 
most unfavorable conditions, is exceedingly erratic ; what 
seems material improvement may again and again be inter- 
rupted by unexpected exacerbation of all the symptoms, thus 
leaving the most experienced practitioner in doubt as to the 
final outcome. 

Treatment. — Absolute rest in bed is essential even in mild 



ACUTE BRIGHT'S DISEASE. 1217 

cases, and must be enforced at once. The room should be well 
ventilated, kept at a uniform temperature, and every possible 
precaution be taken to protect the patient against being 
chilled or taking cold. To this end underwear of light wool or 
Canton flannel must be worn. The bed-covering should be 
just heavy enough to favor a moderate moisture of the skin 
without being oppressively heavy. The diet must exclude all 
articles of food likely to irritate the kidneys. Milk answers 
every purpose, and has long been considered the ideal 
food in nephritis. If for some reason the patient cannot endure 
an exclusive milk diet, it may be varied by allowing butter- 
milk, gruels (arrow-root, oat-meal, flour) or barley-water; in 
some cases chicken-broth may be added. Later, oat-meal or 
cracked wheat may be given in nearly solid form. Water may 
be drunk freely, and some writers advise that from five to six 
quarts of liquid be given daily if the stomach does not rebel. 
Hot or warm drinks are preferable ; iced drinks are absolutely 
forbidden. Alkaline mineral waters may be used. Osier rec- 
ommends a drink made by dissolving a drachm of cream of 
tartar in a pint of boiling water, to which may be added the 
juice of half a lemon and a little sugar. A very little weak red 
wine may be taken once in a while, if there is a craving for it. 
Repeated dry cupping over the kidneys is strongly urged by 
American clinicians, especially in the early stage; it seems of 
doubtful value. 

The chief object of the general treatment is to prevent the re- 
tention of the urinary constituents in the body ; hence, every 
effort must be made to increase the action of the skin and to 
keep the bowels open. It would be desirable to stimulate the 
kidneys by the exhibition of diuretics, were their use not coun- 
ter-indicated by the irritation which these substances occasion 
in the kidneys. The bowels can be kept open by the intelligent 
use of salines. Sweating can usually be induced by the use of 
hot water, and measures calculated to keep the skin in a state 
of high activity should be employed even before there is an ap- 
pearance of oedema. In children the wet pack is probably 
more convenient than the bath. The child should be wrapped 
in a heavy blanket -wrung out of hot water, covered with a 
dry blanket and rubber-sheet, and kept in the pack for at least 
an hour ; this may be done twice daily. In adults the hot bath 
77 



1218 DISEASES OF THE KIDNEYS AND BLADDER. 

is preferable. The water should be gradually brought to a 
temperature of 95° to 100°, and the patient kept in it for at 
least fifteen to twenty minutes ; he is then rapidly wiped dry, 
wrapped in a warm sheet or blanket, and put to bed. The use 
of a cool compress on the head and of an occasional sip of cool 
water will prove safe and grateful to the patient. He should 
remain, thus wrapped, for about three hours. The greatest 
care must be exercised not to let the patient get chilled. 

The great usefulness of these hydropathic measures is gener- 
ally recognized. In some cases, however, the}' are utterly in 
vain; nothing will bring about free sweating. In others, 
baths are not well borne; the}' must never be allowed 
when the patient suffers from d}'Spncea or cardiac weak- 
ness ; here the wet pack in bed must be taken as a substitute. 
If the skin remains dry in spite of all these attempts to bring 
on sweating, pilocarpine (gr. Vs to V3 in an adult; gr. 
^0 to -^ in a child from two to ten years of age) ma}' be used 
by the mouth or hypodermically ; in either case great caution 
must be exercised, since this measure is not free from danger. 
If the dropsy becomes extreme, and all other agents fail, the 
skin may be punctured by lancet or aspirator, and escape of 
the fluid secured by means of a small silver canula or, in case of 
the aspirator needle, by drainage through a long narrow tube, 
with the vessel on the floor. Aspiration may have to be per- 
formed if pressure of fluid in the pleural cavity results in dis- 
tressing dyspnoea. In case of ascites, paracentesis may be in- 
dicated. Acute suppression of urine demands active sweating 
and even saline diuretics. In desperate cases the application 
of hot flannels saturated with the tincture of digitalis or of 
poultices of the leaves of digitalis over the loins has been rec- 
ommended in spite of the fact that this practice is not free 
from great danger of collapse. Ursemic convulsions, if severe, 
demand the use of chloroform, especially when they occur dur- 
ing pregnane}^. In milder cases, when the convulsions are not fre- 
quent, tepid baths with cold showering are said to be helpful. 
Dry cupping of the loins, pilocarpine, the wet pack, purgatives 
and, in adults, free venesection are recommended. If vomiting 
is severe, it is often much relieved by the use of oxalate of 
cerium or bicarbonate of sodium in the milk. It may be neces- 
sary to restrict the diet. If the vomitus contains ammonia, 



ACUTE BRIGHT'S DISEASE. 1219 

ten to fifteen drops of dilute hydrochloric acid should be given 
in water three or four times daily. If uncontrollable by other 
means, it may be necessary to have recourse to bits of cracked 
ice. Much attention should always be paid to the condition 
of the heart and arteries ; if the latter are contracted, nitro- 
glycerine, chloral hydrate or opium may be called for ; if the 
heart's action is feeble, digitalis, strophanthus and caffein, 
with alcoholic stimulants, are of value. 

Therapeutics. — Aconite is of service only in idiopathic cases 
following exposure, with much congestion, and possibly diffi- 
cult, burning, painful urination. Chill and characteristic fever. 
— Apis mellifica. Aching in the lumbar region, with soreness 
in the region of the kidneys and bruised sensation in the ab- 
dominal avails on deep pressure. Urine dark, scanty, almost 
suppressed, loaded with casts ; extensive dropsy, with absence 
of thirst ; restlessness ; dryness of the skin. Under the exhibi- 
tion of the Apium virus, especially in cases of post-scarlatinal 
nephritis, I have seen brilliant results, the urine rapidly in- 
creasing, with lessening of albumin, and, often, comparatively 
rapid disappearance of the dropsy. It has proved of great 
value when dyspnoea was marked, also when brain symptoms 
of pronounced character were present. — Arsenicum. The urine 
is dark, turbid, bloody, albuminous, and often voided with 
much burning pain. CEdema and dropsy. There may be gas- 
trointestinal irritation, with characteristic vomiting and 
thirst. The characteristics of the remedy are so strongly im- 
pressed upon the patient that they are easily recognized. — 
Cantharides. Severe inflammatory, lancinating pains in the 
region of the kidneys, extending into the lumbar region ; they 
appear suddenly, are intense, and momentarily arrest breath- 
ing. The characteristic dysuria may be present. Urine scanty, 
bloody, albuminous, full of casts. Of service only in the early 
stage of nephritis. — Hellebore. Subacute nephritis, with 
complete suppression of urine, or scanty, very dark urine. 
Dropsy. Especially useful in children, after scarlet fever. — 
Hepar sulphur, calc. Soreness in the region of the kidneys, 
with constant urging to urinate ; diarrhoea ; albuminous urine ; 
oily film on the surface of the urine. After abuse of mercury.- 
In diphtheritic cases. — Mercurius (corrosivus). Urine scanty, 
sometimes bloody, of strong smell, purulent, with whitish^ 



1220 DISEASES OF THE KIDNEYS AND BLADDER. 

flocculent, shreddy sediment; burning and tenderness. Pain 
in the back, of a dull character ; very moderate fever. — Phos- 
phorus. Urine scanty^, dark-colored, with whitish sediment, 
containing fatty casts. — Terebinthina. Dull, burning pain in 
the region of the kidneys, extending into the bladder, with 
strangury and bloody, albuminous urine. Nephritis following 
an acute disease. 



CHRONIC BRIGHT'S DISEASE. 

The processes described under this head continue for months 
and, sometimes, \ r ears. Two forms are distinguished : Chronic 
Parenchymatous Nephritis and Chronic Interstitial Nephritis. 

CHRONIC PARENCHYMATOUS NEPHRITIS. 

Synonyms. — Chronic Desquamative Nephritis. Chronic Tub- 
ular Nephritis. Chronic Diffuse Nephritis with exudation. 
Large White Kidney. Secondary Contracted Kidney. Second 
Stage of Bright's Disease. 

Etiology. — Until recently it was thought that this affection 
in the majority of cases followed acute Bright's disease, prac- 
tical^ constituting a second stage of that disease ; hence the 
name " Second Stage of Bright's Disease " (Frerichs). It is now 
known that this occurs only in exceptional cases, as occasion- 
ally in scarlet fever or in the acute nephritis of pregnancy, when 
the patient, instead of recovering, gradually drifts into chronic 
kidne}- disease. It is, however, not well to wholly overlook 
the possible connection of chronic nephritis with acute infec- 
tious fevers. As yet, no specific etiological factor has been 
found ; if of toxemic or infectious origin, we are ignorant of it. 
The disease is seen much oftener in men than in women, usually 
before middle life, rarery in the \ oung or old. Malaria, chronic 
anaemia, chronic suppurative processes in almost any of the 
structures of the body, syphilis, tuberculosis and cancer are 
connected with it. Persons who are in the habit of drinking 
large amounts of beer and alcohol appear to furnish many 
victims. 



CHRONIC PARENCHYMATOUS NEPHRITIS. 1221 

Morbid Anatomy. — Struempell and others emphasize the 
pathological entity of the various forms of Bright's disease and 
the fact that in the essentials these forms differ but little, save 
in their duration and in the progressive changes worked in the 
cases which persist for years as compared with those of com- 
paratively brief duration. 

The so-called "Large White Kidney" (Wilks) is the most 
common form. The kidney is enlarged or of normal size, more 
frequently the former ; the capsule is thin and sometimes adheres 
in spots ; the surface is smooth, white or of pale gray, mottled 
with white or yellowish specks ; the stellate veins are injected. 
Upon section the cortex is found to be swollen, of yellowish- 
white color, more or less mottled as the result of fatty degener- 
ation of the epithelium of the convoluted tubes. There is 
usually congestion of the pyramids; hence they appear red- 
dened. The microscope shows more or less destruction of 
renal tissue, with moderate increase of interstitial connective 
tissue. The epithelium is granular and has undergone exten- 
sive fatty degeneration; the glomerular epithelium may be 
proliferated or desquamated. Tube-casts abound in the uri- 
niferous tubules, and hyaline changes are marked in the epi- 
thelium and vessels. The glomeruli are enlarged, their capsules 
thickened, and epithelial changes extensive. Trifling hemor- 
rhagic effusions are common here. When the hemorrhagic 
effusions are large, into and about the tubes, this fact consti- 
tutes chronic hemorrhagic nephritis, in which case the an- 
atomical changes peculiar to the large white kidney are pres- 
ent, the organ itself presenting a grayish-red appearance, and 
the mottly consisting of darkened, hemorrhagic spots with 
lighter gray or yellow spots of anemic fatty tissue. — Small 
White or Pale Granular Kidney denotes a step further in the 
process of destruction, and may therefore be considered second- 
ary to the Large White Kidney, although the claim is made 
that this cannot always be shown to be true. The kidney here 
is of almost normal size, with thickened capsule and granulated 
surface. There is extensive formation of connective tissue 
which takes the place of the destroyed renal tissue, with more 
or less extensive cicatricial contractions. The density of the 
organ is increased ; in color it usually is reddish-gray and mot- 
tled, the atrophied parts appearing reddish. On section, resist- 



1222 DISEASES OF THE KIDNEYS AND BLADDER. 

ance to the knife is found greatly increased ; the cortex is re- 
duced, with many foci consisting of accumulation of fatty epi- 
thelium in the convoluted tubules. The arteries are frequently 
much thickened. The striking changes in distant organs con- 
sist of hypertrophy of the left heart and thickening of the blood 
vessels. The term "secondary contracted kidney" has been ap- 
plied to this form to distinguish it from the genuine contracted 
kidney described hereafter. 

Symptoms. — When the chronic form is the sequel of acute 
nephritis, it will be impossible to draw the line between the 
two or to describe the initial symptoms of the former. But 
in nearly all cases the disease is insidious. There is more or less 
indisposition, loss of appetite and strength, general dulness, 
pallor and headache. These develop so gradually that slight 
attention is paid to them, and no uneasiness is felt until 
oedema appears. This, here, is quite liable to first show itself 
about the ankle and legs, more rarely in the face. In the ankles 
it is always worse at night and much better in the morning ; 
puffiness of the face is most noticeable in the morning. In 
every case it is slowly progressive. The urine is always dimin- 
ished in amount, two pints or less in the twenty -four hours, 
and may- be exceedingly scanty. It is smoky, sometimes of a 
dark, blackish red, from the presence of blood; turbid; often of 
a dirty -yellow; acid in reaction, of high specific gravity (1.020 
to 1.025); which, however, is lowered during the latter part of 
the disease. Upon standing a heavy sediment is deposited, con- 
sisting of tube casts, leucocytes, blood corpuscles, hyaline, epi- 
thelial, granular and fatty casts. These must be carefully ex- 
amined and especial attention paid to the deposits which cover 
them, since they throw important light upon the inroads al- 
ready made upon the renal tissues. The constant presence of 
large amounts of blood shows that we are dealing with a case 
of chronic hemorrhagic nephritis, and an abundance of fat 
granules and fatty granular cells, or of a greasy', lustrous layer 
on the urine, indicates large, white kidney. There is always a 
deficiency of urea and a large amount of albumin, especially in 
the urine voided during the day, often amounting to one-half 
of the urine boiled, and representing a daily loss of albumin 
which may reach from four drachms to an ounce.— Dropsy is 
pronounced and obstinate. The severer the case, the greater 



CHRONIC PARENCHYMATOUS NEPHRITIS. 1223 

the dropsy, save in the atrophic form, where the urine may be 
increased with a corresponding diminution in the dropsical effu- 
sion. It is general, with a tendency to effusion into the serous 
sacs. Osier points out that in large, white kidney the complex- 
ion is often peculiarly pasty, the pallor marked, and the eye- 
lids pronouncedly cedematous. — JJrsemia is common, and, as in 
acute nephritis, largely responsible for the obstinate headaches 
and vomiting which trouble the patient. Uremic convulsions 
may occur, although less often than in interstitial nephritis. 
Albuminuric retinitis is present in some cases, with retinal 
haemorrhage or the appearance of white spots or streaks, espe- 
cially near the optic nerve. — Vomiting frequently is severe and 
obstinate ; there may be constipation or diarrhoea, and ulcera- 
tive and dysenteric processes, sometimes fatal, may take place 
in the colon and ileum. — Headache, of anaemic or urasmic ori- 
gin, often is distressing. — The circulatory system shows char- 
acteristic changes in the increased tension of the radial pulse, 
increasing stiffness of the vessels, and the cardiac hypertrophy, 
with or without dilatation, which invariably develops, save in 
cases where there is such utter physical exhaustion that not 
sufficient nutritive material can be spared to bring about the 
hypertrophy. In the presence of extensive dropsy many of the 
physical signs of cardiac hypertrophy may not be available ; 
but the character of the radial pulse, the displacement and in- 
creased force of the apex beat, and the accentuated aortic sec- 
ond sound will lead to a recognition of the hypertrophy. Com- 
plications of a serious character are: oedema glottidis, bronchi- 
tis, pneumonia, pulmonary oedema, hydrothorax, more rarely 
endocarditis and pericarditis. 

Prognosis. — The course of chronic nephritis is protracted and 
uniform, running from a few weeks to two or three years, dur- 
ing which time, in tedious cases, exacerbations and remissions 
may be quite frequent. The most protracted cases are those of 
small, white kidney. Recovery may take place, especially when 
the disease, as sometimes happens, is limited to a small portion 
of the kidney ; but generally the prognosis is exceedingly seri- 
ous, and a case which has run for more than a year may be con- 
sidered almost hopeless. Death occurs from extensive effusion 
with oedema of the lungs or larynx, from secondary inflamma- 
tion of the serous cavities or of the lungs, or from uraemia. 



1224 DISEASES OF THE KIDNEYS AND BLADDER. 

Diagnosis. — No difficulty can be experienced in recognizing 
chronic Bright's disease. Differentiation between the various 
forms rests chiefly upon examination of the urine. In chronic 
heemorrhagic nephritis the urine is rich in red blood corpuscles 
and casts ; the duration of the disease is from six to eighteen 
months. In the large white kidney traces of blood are slight 
or absent. There are fatty granular cells or drops of fat in the 
urine, which is markedly albuminous. (Edema is strongly 
marked. Death from uraemia is frequent ; duration six to eigh- 
teen months. — Small white kidney (secondary contracted) runs 
a longer course, sometimes three years. After the case has run 
for a long time the urine becomes more abundant and the 
cedema is much improved. Death usually occurs from cardiac 
insufficiency, with increased dropsy or uraemia. 

Treatment. — The treatment is that of acute nephritis. The 
patient must be kept warm, and should lie quietly in bed. If 
able to be about, heavy woolen undergarments must be worn. 
Since many of the symptoms are relieved by residence in a 
warm equable climate, at least the winter months should be 
spent in the South ; but even here particular care must be exer- 
cised to protect the patient against exposure and strong, chilly 
currents of air, especially near the sea-coast. The diet must be 
plain, non-nitrogenous, and will consist chiefly of milk, prefer- 
ably skim-milk, butter-milk, and koumyss, with oat-meal and 
other farinaceous substances well cooked. Pure water should 
be drunk freely. The patient should take at least three quarts 
of liquid in the twenty-four hours. The dropsy demands the 
treatment described in the preceding chapter. The systematic 
use of vapor baths, taken according to the strength of the pa- 
tient, is very important, and must be rigorousry maintained, 
even as often as twice each day, if uraemic symptoms threaten ; 
the use of pilocarpine, elaterium, and other agents likely to re- 
lieve the strain upon the kidneys, is also indicated. Surgical 
treatment of dropsy should be delayed as long as possible. The 
condition of the heart will sooner or later demand the exhibi- 
tion of digitalis, strophanthus and caffeine. The strontium 
salts, it is thought, exert a favorable action upon the nutrition 
of the kidneys, and on that account the employment of the 
lactate of strontium, thirty to fifty grains per day, in divided 
doses, has been highly recommended. Iron (ferric chloride, 1 



CHRONIC INTERSTITIAL NEPHRITIS. 1225 

to 3 grs.) is still a favorite prescription with many. — Arsen- 
icum, Mercurius (solubilis or corrosiyus) and Phosphorus 
are the most promising constitutional remedies. 

CHRONIC INTERSTITIAL NEPHRITIS. 

Synonyms. — Contracted Kidney. Granular Kidney. Gran- 
ular Atrophy of the Kidney. Sclerosis of the Kidney. Renal 
Sclerosis. Gouty Kidney. Third Stage of Bright's Disease (?). 

The essential feature of contracted kidney is a continuous 
and progressive atrophy of the renal tissue, with correspond- 
ing increase of interstitial connective tissue. It occurs occasion- 
ally as a sequence of chronic parenchymatous nephritis, but 
oftener as an independent primary disease, frequently associ- 
ated with arterio-sclerosis. 

^Etiology. — The frequency of chronic interstitial nephritis in 
the latter part of life, from forty to sixty years of age, renders 
it probable that in many cases it may be considered a part of 
the general breaking up of the system which characterizes ad- 
vanced years, a proposition rendered the more probable from 
its close relationship to arterio-sclerosis. Predisposition to con- 
tracted kidney is strongly marked in many cases, and here 
again family tendency to both renal sclerosis and sclerosis of 
the vessels go hand in hand. Whatever irritates the kidneys 
necessarily increases this tendency; hence generous living, fond- 
ness of and indulgence in a diet largely composed of meat, with 
insufficient exercise, much worry and close application to busi- 
ness, account for the frequency of the disease among the better 
classes. Among the specific causes the poison of syphilis, alco- 
hol, malaria and lead (type-setters and painters) are to be men- 
tioned. Gouty, rheumatic and lithffimic conditions are predis- 
posing causes. 

Morbid Anatomy. — The kidneys are greatly reduced in size, 
even to one-half or one-third of normal ; they are dense and firm 
to the touch. The capsule is thick and adherent, so that it can- 
not be stripped off without removing parts of the underlying 
tissues. The surface is irregular, nodular, granular, the raised 
portions appearing of darker color than the depressed parts; 
small cysts are sometimes seen on the surface. The color usu- 
ally is dark red or reddish. The cortex is thin and pale; the 



1226 DISEASES OF THE KIDNEYS AND BLADDER. 

p3 , ramids are short, wasted, rather pale, with occasional 
striated uric acid formations in the gouty contracted kidney. 
The small arteries are conspicuous and thickened. The organ is 
resistant to the knife and embodied in a thick layer of fat. Mi- 
croscopically there is atrophy and degeneration of the secreting 
structures with corresponding increase of interstitial connect- 
ive tissue, more advanced than in chronic parenchymatous ne- 
phritis. The fibrous elements are especially abundant in the 
cortex. Small-celled infiltration between the tubes and around 
the glomeruli is seen in the early stage ; later it becomes fibril- 
lated. The glomeruli show capsular thickening and increase in 
the cells of the tufts ; more advanced changes are atrophy and 
hyaline degeneration. The presence of constantly increasing 
connective tissue leads to atrophy of the tubules with eventual 
disappearance of the epithelium. Granular, fatty, and hyaline 
changes in the epithelium and dilated tubules, containing epi- 
thelial debris and tube-casts, constitute the projecting granules. 
The dilatation of the tubules may be sufficient to from small 
cysts. Pigmentation from haemorhage is rare. The arteries 
show atheromatous and sclerotic changes. 

Arterio-sclerosis and cardiac hypertrophy are constant ; the 
enlargement of the heart ma} r involve the left ventricle or may 
be general, and in exceptional cases ma}^ be enormous. 

"The combination of chronic fibrous nephritis and the deposi- 
tion of urates is spoken of as a gouty kidney, and is often found 
among persons leading a life of luxury; while the fibrous kidney 
associated with lime salts has been regarded as evidence of a 
poor man's gout" (Wood and Fitz). 

Symptoms. — In many cases, perhaps in a majority of them, 
the existence of sclerotic kidney is not suspected until failing 
eye-sight brings the patient under the care of a specialist and 
examination of the eye demonstrates the presence of eye-symp- 
toms which unmistakably point to serious renal lesion, or 
when a careful examination is made for the purpose of securing 
life insurance. It is not infrequent to have death occur from 
uraemic poisoning or from cerebral haemorrhage, a post-mortem 
examination disclosing evidence of advanced renal affection in 
persons who had appeared in, at least, average good health. 
In others, suspicion is aroused b\ r the continuous development 
of a long train of symptoms consisting chiefly of great exhaus- 



CHRONIC INTERSTITIAL NEPHRITIS. 1227 

tion, sleeplessness, headache, poor appetite, indigestion, diffi- 
culty of breathing on exertion and, possibly, failure of eye- 
sight ; if, with these, the patient is obliged to urinate frequently 
at night it is reasonable to presume that disease of the kidney 
is developing. 

The urinary symptoms are of extreme importance. At first 
the amount of urine is less than normal, somewhat albumi- 
nous, and the solid constituents are diminished. Later, com- 
pensation is established, the blood pressure raised, and *the 
amount of urine voided is greatly increased. It is at this period 
that the case is likely to come under the observation of the 
medical man. The urine now is copious, from two to four 
pints being passed in the twenty-four hours, the patient's rest 
being broken by the necessity of repeatedly emptying the blad- 
der during the night. The urine is acid, clear, of light-yellow 
color, of a specific gravity varying from 1.005 to 1.010 or 
1.012, and usually with scanty sediment, deficient in solid con- 
stituents, but often containing a full percentage of urea. The 
sediment may contain a few hyaline or granular casts, rarely 
leucocytes, renal epithelium, red blood corpuscles or fat. In ex- 
ceptional cases a habitual tendency to bleeding is noticed, espe- 
cially after taking violent exercise, and the urine then has a 
pale smoky appearance. In the late stage of renal sclerosis the 
urine may again be diminished and richer in albumin ; this is 
especially the case when there are complications with bronchi- 
tis or dyspepsia. The pulse soon assumes a hard, tense charac- 
ter, due to stiffness of the artery. This symptom is of great 
practical importance. Osier calls attention to the fact that the 
thickness of the vessel may be ascertained by eradicating the 
pulse wave in the radial and feeling the vessel wall beyond it. 
If normal, the arterial coats under these circumstances cannot 
be distinguished from the surrounding tissues; if thickened, the 
vessel can be rolled beneath the fingers. Cardiac hypertrophy 
becomes a physiological necessity in order to overcome the re- 
sistance in the arteries, and is absent only in persons so weak 
or cachectic that a compensatory effort cannot be successfully 
made. The hypertrophy may involve the left heart only, or it 
may be general and very great. The physical signs peculiar to 
this condition are present; but examination of the heart is 
often rendered difficult and unsatisfactory by existing pulmo- 



1228 DISEASES OF THE KIDNEYS AND BLADDER. 

nary emphysema, especially in old persons. In due time, dila- 
tation of the heart takes place, followed by the long and dis- 
tressing train of symptoms peculiar to that state, including 
oedema and general dropsy. The severe headaches from which 
patients in this condition often suffer are in part due to the 
condition of the heart ; they are largely anaemic in character, 
usually one-sided, shooting into the back of the neck, and are 
associated with vertigo, troubled sleep and despondency. — 
Respiration is almost always a trifle labored, and assumes 
later on the t}'pe of a fixed dyspnoea, especially at night, often 
resembling asthma ; it is partly of uraemic, partly of cardiac, 
origin. Cheyne-Stokes breathing may be noticed, not only to- 
ward the end, but when the patient is still able to be about. 
There is great liability to attacks of bronchitis, particularly 
during cold weather ; lobular pneumonia is an occasional com- 
plication, and pleural effusions and pulmonary cedema may oc- 
cur, often proving rapidly'- fatal. Exceptionally, oedema of the 
glottis is seen. — Vomiting may be violent and uncontrollable 
from the start, and may be due to uraemic poisoning. In other 
cases severe and even fatal diarrhoea is present. In still others 
the digestive system is less disturbed, but there is always more 
or less foul coating of the tongue, heavy and urinous breath, 
loss of appetite and insufficiency of digestive power. — Uraemia. 
Danger of uraemic poisoning increases with increasing scanti- 
ness of urine, but pronounced symptoms of it may suddenly ap- 
pear when an almost normal amount of urine is voided ; again, 
the patient's condition may be threatening, and yet recovery 
take place ; the condition, however, is always serious. Various 
expressions of uraemia have been described. One of the most 
interesting is the failure of vision and eventual blindness which 
occur with especial frequency' in this form of renal disease. 
Sometimes, as already stated, failure of vision affords the first 
clue to the real condition of the patient's health. Flame-shaped 
or multiple haemorrhages, diffuse retinitis and papillitis are the 
commoner affections of the eye seen in this connection. Ring- 
ing in the ears, with dizziness and deafness, are not infrequent. 
— The nervous system. In addition to the disturbances of the 
nervous system which are due to uraemia, the most serious is 
cerebral apoplexy, the result of increased pressure in vessels 
whose walls are weakened by sclerosis. It is by no means un- 



CHRONIC INTERSTITIAL NEPHRITIS. 1229 

common. It may take place into the meninges or cerebrum, 
and may pass off with a resultant hemiplegia or prove fatal. 
Neuralgia in different parts of the body is frequent. Haemor- 
rhage occurs into the skin, stomach, intestines, lungs, or from 
the nose ; in rare cases it seems as though a hemorrhagic dia- 
thesis were developing. The bleeding depends upon arterio- 
sclerosis. Cases of fatal epistaxis are reported by many 
writers. The skin usually is pale and dry. Sweating is un- 
common, and when it takes place a deposit of urea may be left 
on the skin, especially on the face. Eczema is frequent. In many 
cases much suffering is caused by intolerable itching of the skin; 
others suffer much from cramping of the muscles. As stated, 
oedema and dropsy are comparatively rare, though puffing of 
the ankles is not unusual ; if extensive, the condition is due to 
existing heart failure or, in cases of ascites, to cirrhosis of the 
liver. Of complications, pneumonia is the more common. 

Duration and Termination. — In view of the difficulty of fixing 
the onset of renal sclerosis, the probable duration of any given 
case can rarely be accurately determined. The affection, how- 
ever, is not incompatible with a fair degree of useful activity 
and many years of life, cases having been under observation for 
ten and fifteen years. In the absence of exceptionally severe fea- 
tures, as uraemic poisoning, the issue of the case depends almost 
entirely upon the ability of the heart to carry on its work — i. e. 
upon its "staying" qualities — and much can be done to main- 
tain this indefinitely. As soon as heart failure sets in, an early 
fatal termination becomes inevitable. Frequent periods of im- 
provement also tend to spin out life, while, on the other hand, 
the hope of continued fair health may be cut short by an unex- 
pected exacerbation of symptoms or by some fatal complica- 
tion. A cure, at the present state of medical science, cannot be 
expected. 

Diagnosis. — The diagnosis is exceedingly difficult in the early 
stage of the disease if the first examination is made immediately 
after a sudden attack of uraemia or cerebral apoplexy, and late 
in the disease if the patient is first seen after dilatation and 
failure of the heart has taken place. In the latter case differ- 
entiation from some form of cerebral disease is surrounded 
■with great uncertainty, and in case of heart-dilatation the 
symptoms of the primary disease are likely to be wholly ob- 



1230 DISEASES OF THE KIDNEYS AND BLADDER. 

scured by those of the cardiac affection. It is a consolation to 
know that for practical purposes the diagnosis under such con- 
ditions is of slight moment. In the average case the diagnosis 
rests upon the results of urinary analysis, the quality of the 
pulse, the existence of thickening of the walls of the vessels, signs 
of cardiac h3 r pertrophy (left ventricular or general) and the 
presence of such disturbances in the retina as have been de- 
scribed. The examinations of the urine must be made often 
and with great care, especially so when no albumin has been 
detected, and should cover the evacuations made both morning 
and evening. 

Treatment. — The inability to cure a contracted kidney ren- 
ders of double value all measures calculated to increase the op- 
portunity for continued life and usefulness by carefully watching 
over the heart, arteries and kidney's. In persons of middle life 
nothing is as likely to reduce to a minimum the danger of renal 
sclerosis as the habitual use of the Turkish bath, under proper 
precautions. The disease once established, every effort must be 
made to place the patient under the most favorable surround- 
ings. If at all possible, a permanent residence must be found 
in a warm, even climate, such as Southern California offers ; 
there he can live in the open air, away from many of the temp- 
tations, worries and inclemencies of the Eastern and Northern 
states, and thus exhaust to the full the advantages arising from 
a normal, natural life. The bowels are to be kept open and the 
skin kept in a healthy condition by regular bathing. The kid- 
neys must be freely and constantly flushed by copious draughts 
of pure water. The diet must be light and nourishing, eating 
meat not oftener than once a day at the very most ; alcoholic 
drinks are to be interdicted, and tea and coffee taken in great 
moderation, if at all. 

The necessity of special medication does not arise until spe- 
cial conditions or symptoms demand attention. Thus, if the 
pulse tension is evidently too high, with headache, dizziness and 
oppressed breathing, the administration of nitro-glycerine, one 
minim of a one per cent, solution (2x) three times a day, grad- 
ually increased, and maintained for some weeks, will usually 
afford relief. The remedy should be discontinued after some 
weeks, to be renewed when necessary. Cardiac dilatation and 
heart failure demand the treatment given under their appro- 



AMYLOID DISEASE. 1231 

priate heading. If anaemic, Arsenic, China, Iron (preferably 
the perchloride of iron), Phosphorus, and others, are to be con- 
sulted. In case of ursemic poisoning the bowels are to be 
opened by a brisk saline purge, and sweating induced by the use 
of hot baths or of subcutaneous injections of pilocarpine, as in 
acute diffuse nephritis. The homoeopathically indicated reme- 
dies are those given under the same heading, to which may be 
added as possibly useful the following: Aurum, when there is a 
mercurial or syphilitic taint. Vertigo. Characteristic nervous 
symptoms; tendency to hypochondriasis.— Benzoic acid, in 
cases of gouty diathesis, with vesical catarrh and very offen- 
sive odor of the urine. — Nitric acid in syphilitic subjects ; after 
abuse of mercury ; in necrotic conditions of bony tissue. Skin 
dry and hot. CEdema of the lower leg. Urine muddy, scanty, 
of foul odor. 

AMYLOID DISEASE. 

Amyloid, waxy, or lardaceous degeneration of the kidneys 
may be looked upon as part of a special degenerative process 
involving other organs of the body, especially the spleen, liver 
and intestine. It may occur in connection with previously ex- 
isting renal disease, more often in chronic diffuse nephritis and 
sclerosis of the kidney, or without it. The conditions which 
favor amyloid degeneration are great general weakness and 
profound cachexia, usually associated with ulceration and 
cavity-formation. Here belong: chronic tuberculous processes, 
especially of the lungs, also of the intestine, with ulceration ; 
chronic suppuration anywhere, but particularly of bony tissue 
and joints ; syphilis, with ulcerations and tertiary disease of 
bones and mucous membranes; also the chronic suppuration in 
old, chronic ulcers ; saccular bronchiectasis ; fistulas ; ulcerating 
new-growths ; all diseases characterized by extensive and long- 
continued formation of pus. 

Morbid Anatomy. — Amyloid degeneration of any organ be- 
gins in the wall of the small vessels and may, and usually does, 
later affect the interparenchymatous connective tissue, but 
rarely involves the parenchymatous cells proper, as the liver 
cells or renal epithelium. The walls of the affected vessels be- 
come much thickened, assume a homogeneous, lustrous appear- 
ance, and yield a reddish-brown or mahogany color when 



1232 DISEASES OF THE KIDNEYS AND BLADDER. 

treated with compound solution of iodine. If the amyloid de- 
generation is extensive, the affected organ becomes lardaceous, 
bacon-like, in appearance. In the amyloid kidney associated 
with some other form of renal disease the picture is necessarily 
complex, and for the sake of brevity the anatomical changes 
peculiar to chronic diffuse nephritis and contracted kidney need 
not be here repeated. In slight cases of amyloid kidney the or- 
gan may appear normal to the naked eye and the microscope 
show only insignificant arr^doid changes in the walls of the ves- 
sels in the cortex and medullary substance. In the t3 r pical 
large white amyloid kidney there is enlargement of the organ ; 
the surface is smooth, of grayish-white color, sometimes mot- 
tled. On section the cortex appears yellowish-white and ab- 
normally large ; the glomeruli are large, appearing as dull, lus- 
trous, translucent points. The pyramids are deep-red. Traces 
of haemorrhages are rare. The microscope in pure amyloid kid- 
ney demonstrates amyloid degeneration in the glomeruli, the 
capillaries of the cortex, vasa recta, and sometimes the mem- 
branous portion of the tubules, with a normal condition of 
other renal tissue. More often, however, there is diffuse nephri- 
tis, or other renal lesion, with characteristic anatomical 
changes. 

Symptoms. — As seen in the sick-room, it is often difficult to 
distinguish the symptoms of simple amyloid degeneration of 
the kidne} r s from those caused by primary renal lesions. If tri- 
fling in extent, no characteristic symptoms whatever may be 
produced. If well advanced, the urine is abundant, acid, pale- 
yellow, clear, and rich in albumin, often containing two percent, 
of the latter. According to Senator, globulin may be present 
in addition to the ordinary albumin. The specific gravity is 
rather low ; it varies greatly in different cases and at different 
times in the same individual. There usually is little sediment; 
it contains some Iryaline casts and leucocytes, possibly 
a few red blood corpuscles and fatty, waxy, finely granular 
casts ; but the latter are more characteristic of coexisting renal 
inflammation than of the purely amyloid state. Dropsy is a 
frequent, but not a constant, S3 r mptom, and is undoubtedly 
most pronounced in profoundly anaemic or cachectic subjects. 
Diarrhoea is common, and may be quite severe ; it may arise 
from tuberculous ulceration or amvloid of the intestine. In ad- 



PYELITIS. 1233 

dition, there may be hypertrophy of the heart and uraemia, but 
these belong to coexisting disease of the kidney and are in no 
wise connected with amyloid disease pure and simple. Albumi- 
nuric retinitis can hardly be associated -with amyloid disease 
proper and compensatory cardiac hypertrophy is practically 
impossible in the utterly low and cachectic condition with 
which amyloid degeneration is so intimately connected. Symp- 
toms of amyloid degeneration in other organs are likely to ex- 
ist and impress themselves upon the case ; splenic, hepatic and 
intestinal disease are especially important, and are usually rec- 
ognized without difficulty. 

Diagnosis. — The diagnosis rests upon the existence of suffi- 
cient cause for amyloid degeneration in other organs of the 
body ; evidence of amyloid degeneration in other parts of the 
body; abundant and clear urine, poor in morphological ele- 
ments, rich in albumin. The diagnosis is rendered obscure by 
the presence of profound inflammatory changes in the kidneys. 

The prognosis is that of the primary disease. Since amyloid 
degeneration is in itself an expression of a profoundly cachectic 
state, its existence in any given case must be considered an ex- 
ceedingly unfavorable sign. 

The treatment is that of Bright's disease. 

PYELITIS. 

Pyelitis, pyelonephritis, pyonephrosis, is an inflammation of 
the renal pelvis. Very rarely it occurs as a primary disease, the 
result of exposure, and when so, oftener in children than in 
adults. Usually it is secondary, from extension of inflamma- 
tion in other organs (acute or chronic inflammatory disease of 
the kidneys, cystitis or ureteritis) or in the course of acute in- 
fectious diseases (typhoid fever, small-pox, etc.), in which case 
the attempt at elimination of the offending infectious material 
has resulted in setting up a local inflammation in the renal pel- 
vis. The presence of foreign bodies, especially of calculi, is a 
frequent cause. Irritation from tubercular or cancerous dis- 
ease, of hydatids, the presence of ova of parasites (haamatodes, 
strongylus), irritation from highly saccharine urine, and the 
passing effects of such irritating drugs as cantharides, turpen- 
tine, cubebs, etc., are also important aetiological factors. Cases 
78 



1234 DISEASES OF THE KIDNEYS AND BLADDER. 

may result from bacterial infection, as after operations upon 
the bladder or urethra when rules of surgical cleanliness have 
been violated, or under similar conditions in child-bed. The pres- 
ence of decomposing urine, possibly from pressure of a tumor 
upon the ureter, may also give rise to pyelitis. The affection is 
more common in men than in women, and usually occurs in 
adult life. 

Morbid Anatomy. — In light or earW cases the mucous mem- 
brane is reddened, swollen and turbid, often ecchymotic and 
covered with a sticky secretion which holds pus-corpuscles and 
epithelium. If secondary to cystitis, both kidneys are usually 
involved, and there develops suppurative, ulcerative, and even 
diphtheritic inflammation. Lines of suppuration with injected 
borders extend along the pyramids toward the cortex ; these 
enlarge, become confluent, soften in the center, and form small 
abscesses in the cortex or beneath the capsule. If pyelitis re- 
sults from the continuous irritation of a calculus, a slight pri- 
mary catarrhal irritation of the mucous membrane soon gives 
way to roughening and thickening, and the membrane assumes 
a grayish color. The kidneys themselves are extensively in- 
volved (pyelo-nephritis),and the process terminates with grad- 
ually increasing dilatation of the caryces and resulting atrophy 
of the renal structure, the kidney eventually constituting a sac 
of pus and the renal tissue sometimes completely disappearing. 
In tubercular nephritis the same process occurs. In either case, 
with obstruction of the pelvic orifice, inspissation of pus may 
take place, the kidney constituting a number of small sacs 
which contain a gra3ash, putty-like substance, often abundant 
in lime salts. This inspissation of pus is particularly frequent 
in connection with tubercular nephritis, and then constitutes 
the so-called "scrofulous" kidney. 

Symptoms. — Since pyelitis is nearly alwa\ r s found in connec- 
tion with another and broader lesion, its symptoms usually 
are subordinate to those of the primary disease and lack in in- 
dividuality. In mild cases there is some pain in the back, with 
tenderness to pressure in the affected region. The urine is acid, 
turbid, often slightly albuminous, and may contain a few mu- 
cus and pus cells, possibly some blood corpuscles. Pyuria is 
present in variable degree ; it may be intermittent, occa- 
sional blocking of the ureter on the affected side stopping the 



PYELITIS. 1235 

flow of pus for the time being, the urine, discharged from the 
healthy side, appearing normal ; yielding of the obstruction al- 
lows the escape of the pent-up pus. The pus itself is not in any 
sense characteristic. Tubular casts and fragments of renal tis- 
sue may be discharged with the pus. The urine continues acid, 
unless there is cystitis, in which case it is ammoniacal. Fever, 
with rigors and sweating, is present in most cases ; its appear- 
ance indicates the onset of pyelonephritis. It usually is irregu- 
larly remitting, but sometimes resembles malaria in the regu- 
larity of its recurrence. In some cases it assumes a hectic type. 
It often is accompanied with profound nervous disturbances 
and culminates in coma; when the nervous symptoms appear 
to result from the absorption of decomposing matter in the 
urine, they are grouped under the term "ammoniaemia." Occa- 
sionally a case closely resembles typhoid fever, particularly 
when of tubercular origin. The general symptoms are those of 
a wasting disease ; the patient loses appetite, flesh and strength, , 
and becomes profoundly anaemic ; if secondary abscesses form, 
a pyaemic state prevails. 

Diagnosis. — The diagnosis rests upon the history of the case, 
the presence of pus in the urine, and the absence of pronounced 
vesical tenesmus. It is no longer thought that the appearance 
or arrangement of epithelial cells from the renal pelvis differs 
from those of the bladder. Perinephric abscess may be differ- 
entiated by the presence of an oedematous swelling in the lum- 
bar region, the absence of a clearly defined tumor which is pre- 
sent in many cases of advanced pyonephrosis, the history of 
the case, and the freedom, in some cases, of the urine from pus. 

Prognosis. — The prognosis is favorable in the pyelitis of in- 
fectious fevers or of toxic irritants ; less favorable in cases of 
tubercular origin ; grave in pyelonephritis, in cases preceded by 
disease of the urinary tract, or when surgical treatment is de- 
manded. Recovery, however, may take place in very unpro- 
mising cases. 

Treatment. — Rest, nourishing diet, and a liberal allowance 
of fluids, especially alkaline mineral waters, are important. 
The general health should be carefully looked after, and such 
remedies as Arsenicum, Lycopodium, Terebinthina, Saw 
Palmetto, Silica and Hepar sulph. calc. exhibited as indi- 
cated. The insufficiency of internal treatment must, however, 



1236 DISEASES OF THE KIDNEYS AND BLADDER. 

be admitted. If due to a calculus, measures hereafter described 
will have to be considered. If depending upon cystitis, vesical 
irrigation and drainage will become necessary and appro- 
priate medication is of great service. Empirically, the internal 
administration of boric acid, ten grains three to six times daily, 
has been thought useful. If all these prove ineffective, and par- 
ticular^ when there is increasing enlargement in the region of 
the kidney with aggravation of the constitutional symptoms, 
the case must be promptly transferred to the surgical specialist. 

HYDRONEPHROSIS. 

A dilatation of the pelves and calyces of the kidneys, caused 
by the accumulation of non-purulent fluids (urine) from ob- 
struction. The obstruction may occur at any part of the uri- 
nary tract, giving rise to a stasis of the urine back of the ob- 
struction, followed by constantly increasing dilatation above. 
If the obstruction be in the ureter, the ureter above and the 
kidne} r to which it is related are involved; the obstruction being 
located in the urethra, both kidneys suffer, and the resultant 
hydronephrosis is bilateral. 

^Etiology. — The conditions leading to nephrosis may be 
classified into contractive, compressive and constrictive. The 
former embrace chiefly inflammatory conditions of one or both 
ureters, with obliteration of their lumen. Among the "com- 
pressive" may be mentioned contraction or twisting of the 
ureters, oblique insertion of the ureter, pressure from without 
by inflammatory processes or from tumors, chiefly ovarian and 
uterine, or from cicatricial tissue. "Obstructive" causes are the 
result of inflammatory action (adhesion, cicatrization) at any 
point within the urinarj^ tract, the lodgment of calculi, new 
growths (tubercular, cancerous) and such affections as cancer 
of the bladder or prostatic hypertrophy with cj^stitis. Hydro- 
nephrosis may be congenital, due to contraction, twisting or 
too high or faulty insertion of the ureter, or to some other con- 
genital malformation. 

The accumulation of the fluid in the pelvis and infundibula 
may give rise to inflammation ; more often the steadily increas- 
ing dilatation, by pressure, results in gradual wasting of the 
organ, increasing yielding of the enfeebled parts, and event- 



HYDRONEPHROSIS. 1237 

ually the formation of a cyst containing a large amount of thin, 
yellowish fluid, rich in urinary salts, urea, uric acid, sometimes 
albumin, and occasionally pus. If the obstruction is rapid and 
complete, the secretion of urine ceases early, even though not 
entirely; hence the dilatation in such cases is not nearly so 
large as in slowly developing incomplete or periodic obstruction 
(as from calculus) ; in the latter the dilatation may be enor- 
mous, and has been mistaken for a large abdominal tumor or 
ascites. 

In case of unilateral hydronephrosis compensatory work may 
be done by the healthy kidney ; hypertrophy of the left heart 
often follows. 

Symptoms. — The symptoms of any given case depend 
chiefly upon the nature of the primary disease. In many cases, 
especially when hydronephrosis depends upon compression by 
a tumor, no symptoms are experienced. The most important 
symptoms are the tumor itself and such organic lesions in the 
kidney as may result from the pressure and dilatation. The 
tumor appears in the region of the affected kidney, gradually 
extending toward the hypochondrium and median line. It is 
usually resistant and moves with the respiratory effort, partic- 
ularly when of moderate size. It presents a smooth surface 
and considerable fluctuation. It may be unilateral or bilateral, 
as one or both kidneys are affected. It often attains large pro- 
portions, and even when unilateral may occupy a very large 
portion of the abdomen. Anteriorly it may be crossed by the 
colon, which, when empty, may be felt, like a movable cord, 
and is easily distinguished, by palpation or inspection, when 
distended ; if the tumor is large, the colon is usually displaced 
laterally. The growth of the tumor is particularly rapid in the 
intermittent form of unilateral nephrosis; here it often is asso- 
ciated with movable kidney, and readily attracts attention 
from the suddenness of its disappearance, with copious dis- 
charge of urine, when the obstruction yields, and by the 
rapidity with which it refills, a process which occasionally goes 
on for years. The character of the tumor is easiest recognized 
when of comparatively moderate size ; when very large, it is 
more readily mistaken for ovarian, or some other abdominal, 
tumor. Its growth usually is accompanied with slight gastric 
uneasiness, eructations, vomiting, diarrhoea or constipation ; 



1238 DISEASES OF THE KIDNEYS AND BLADDER. 

there is often moderate fever. Mechanically it causes dyspnoea 
by interfering with the movements of the diaphragm, and con- 
stipation. All these symptoms disappear promptly when the ac- 
cumulated fluid is emptied. Upon aspiration, in comparatively 
recent cases, the withrawn fluid contains the normal constitu- 
ents of urine ; if of long standing, the contents are sero-mucous. 
If only the healthy kidney secretes, the urine is normal ; if 
there is p3'elitis and c}^stitis, pus and blood are present ; if lesion 
of the kidney exists, as sclerosis, characteristic casts, etc., are 
present. 

The diagnosis depends chiefly upon the appearance of the tu- 
mor, an examination of its contents, and the history of the 
case. Thus, in young children it may readily be mistaken for 
sarcomatous kidney or sarcoma of the retroperitoneal glands. 
An ovarian turn or closely resembles a large Irydronephrosis, but 
the former usually is more freely movable, does not so com- 
pletely fill the deep lumbar region, and its real nature may 
generally be ascertained by a careful examination per vaginam ; 
on the other hand, hydronephrosis may be suspected if the 
colon bears to the tumor the relation above described. Aspira- 
tion will settle the question ; in hydronephrosis the fluid is clear, 
unless rendered turbid by the presence of cell-elements ; it is 
rarely colloid; it is furthermore of low specific gravity, slightly 
albuminous, and contains traces of urea and uric acid. 

Prognosis. — If unilateral or intermittent, the prognosis is not 
serious, and in the latter form permanent recovery may take 
place ; bilateral nephrosis usually terminates in destruction of 
renal tissue proper, and is therefore a very grave condition. 
Cysts may rupture, usually through the peritonaeum, rarely 
through the diaphragm into the lungs ; occasionally rupture 
takes place through the ureter, sometimes with no reaccumu- 
lation. There is danger of uraemia in bilateral nephrosis and in 
the unilateral form when the ureter on the healthy side becomes 
blocked, as from calculus. 

Treatment. — Very little can be done by the physician except 
to relieve pain, keep the patient as comfortable as possible, and 
meet symptomatic indications as they arise. In the intermit- 
tent form, with no threatening symptoms, treatment is nat- 
urally expectant. In acquired nephrosis massage has been 
used, occasionally followed by discharge of the fluid and disap- 



NEPHROLITHIASIS. 1239 

pearance of the tumor; but there is great danger of causing 
rupture of the sac, suggesting the necessity of extreme care in 
the procedure. In the great majority of cases the treatment is 
surgical, consisting of puncture, incision, extirpation of the 
kidney, and establishment of a fistula. In a number of cases 
hydronephrosis has occurred in boys suffering from phimosis, 
an operation for the latter resulting in a complete cure. 

NEPHROLITHIASIS (Renal Calculus). 

Precipitation of the solid constituents of the urine, forming 
concretions of varying size and chemical composition, occur in 
the kidneys and renal pelvis. It is evident that they are likely 
to form slowly around a nucleus, such as is offered by a small 
blood clot, or a shred of epithelium, casts, or the ova of some 
parasite, but of the specific conditions under which such deposi- 
tion is brought about very little is known. The old teaching 
that an excessive meat diet, or the use of drinking water con- 
taining lime, or of new sour wine, are largely responsible for 
the formation of these concretions is no longer entertained. 

Observation shows that renal calculi occur with greater fre- 
quency among the young and the aged than in those of middle 
life, oftener in men than in women, and chiefly among those 
who follow a sedentary occupation. 

The so-called infarcts, seen in the substance of the kidney, 
consist of deposits in the pyramids or at their apices of either 
uric acid (in the new-born or very young infants), urate of soda 
(in gouty persons) or of lime (oftener in the aged), and are of 
comparatively slight importance. The concretions found in the 
pelvis and calyces of the kidney vary in size from a gritty, 
sandy deposit to calculi as large as a pea or a bean or the even 
more extensive formations which occupy a large part of the 
pelvis and constitute a perfect mould of the parts (coral cal- 
culi). They may be single or multiple; of the small "gravel" 
immense numbers have been found. Many calculi may exist 
without producing extensive dilatation of the pelvis or other- 
wise causing serious harm ; a person may periodically and for 
many years pass stones and suffer no mischief save the severe 
pain which accompanies their escape; and the most extensive 
coral formation may exist in the pelves and calyces without 



1240 DISEASES OF THE KIDNEYS AND BLADDER. 

more than moderate induration. In other cases suppurative 
pyelitis and pyonephrosis ma}' be sequels. 

The uric acid formations are lyy far the most common and 
important; they may assume am- of the shapes described. 
They are hard, of smooth uneven surface, of reddish, brown- 
red, blackish color. If large, they are laminated and very 
dense. Oxalate of lime formations are mulberry-shaped, of 
rough surface, studded with little spines or spikes ; they are 
dark-brown and extremely hard. When broken, they often 
present a radiated, but never a laminated, arrangement. It is 
common to find calculi consisting of alternate layers of uric 
acid and oxalate of lime, or of a nucleus of uric acid covered 
with layers of calcic oxalate. Phosphatic calculi are composed 
of phosphate of lime and ammonio-magnesium phosphate, oc- 
casionally with some carbonate of lime. They are of grayish- 
white color, soft, friable. They are not so frequent in the kid- 
ney, the large specimens being found in the bladder. Unlike the 
other varieties, they occur in alkaline urine. Rare forms are 
those composed of cystine, which are of light-yellow color, lus- 
trous, and in appearance resemble wax; of xanthine (hard, 
brown, very rare), carbonate of lime, indigo (dark-blue), and 
urostealith. 

Symptoms. — Small calculi ma} 7 pass out of the kidney, 
through the ureter into the bladder, and be expelled through 
the urethra without any pain or disturbance. This may be re- 
peated many times in the same person. 

Renal colic occurs when a stone of larger size enters the ureter 
and makes its way into the bladder. The attack in some cases 
is preceded by uneasiness and pain in the affected region, often 
extending into the flank, and accompanied with a sense of in- 
tense, deep-seated soreness. More commonly the onset is sud- 
den, possibly after heavy lifting; but it may occur at night, 
rousing the patient from profound sleep. The pain is indescriba- 
ble in its agonizing intensity. It usually involves the renal re- 
gion and the flank of the affected side, extending downward 
into the groin, and often radiating into the abdomen and even 
into the chest. In mam- cases the testicle is retracted, painful 
and swollen, but so far as my observation on others and per- 
sonal experience goes, the keenest suffering is in the flank. 
With the continuous pain is associated an intense, deep sore- 



NEPHROLITHIASIS. 1241 

ness, with frequent paroxysms of acute aggravation ; the suf- 
fering is so great that nausea and vomiting, sometimes hic- 
cough, cold sweat on the forehead, and deathly faintness are 
very likely to occur even in strong and brave men, the pulse in 
the meantime becoming rapid and feeble. In children convul- 
sions are common. Sometimes the temperature rises to 103° 
or 104°. While thus tortured beyond description, the patient 
is tormented by frequent and, usually, ineffectual and very 
painful urgings to urinate; the urine is passed with much 
effort, in small amounts, and often contains blood. At times, 
especially when the pain diffuses itself over the abdomen, there 
is tormenting and fruitless urging to go to stool. The attack 
may last for a few hours or may be continuous for the greater 
portion of the day ; again, periods of severe pain may alternate 
with periods of comparative rest, and the paroxysms may be 
repeated after an interval of days, weeks, months or years. It 
is not unusual to have the patient feel the calculus work its 
way down the ureter, and know the moment it enters the blad- 
der, this event being followed by immediate cessation of the 
acute pain. The paroxysm having ceased, a deep heavy aching 
remains in the side, with much "bruised" soreness and pro- 
found exhaustion, which may continue for several days. The 
urine after the attack may be copious, bloody and is voided 
with increasing ease, but it requires several days before the pa- 
tient recovers his strength or is able to overcome the dread 
of a sudden recurrence of the colic. 

If the stone remains in the kidney, its presence gives rise to 
more or less constant dull aching and soreness in the region of 
the affected organ, and sometimes to severe paroxysms of pain 
in the affected side ; not infrequently the pain is referred to the 
sound side. The urine may be smoky from slight hasmaturia, 
which is often present and is increased from any exertion. At- 
tacks of pyelitis, with pronounced chill, fever (104°), copious 
sweating and severe pain in the back may recur at intervals of 
many months. Purulent pyelitis, with or without pyonephro- 
sis, may develop, or there may be for an indefinite period, some- 
times for years, discharge of pus with the urine (pyuria). 
These are accompanied with emaciation, loss of strength or ir- 
regular fever. In other cases there is little, if any, trouble in the 
renal pelvis, but a chronic diffuse nephritis slowly develops in 



1242 DISEASES OF THE KIDNEYS AND BLADDER. 

the kidne3 r itself, with sighth^ albuminous urine of low specific 
gravity and such changes and risks as belong to this condi- 
tion. Should a calculus in its descent toward the bladder be- 
come impacted, the result is serious. If the ureter of only one 
kidney becomes obstructed, the accident will cause hydrone- 
phrosis or pyonephrosis ; if there is but one kidnej^, or if the 
other kidney be already unfit, from disease, to carry on its 
work, or if the ureters of both kidneys become obstructed, to- 
tal suppression of urine follows, with uraemia which is likely to 
prove fatal. 

Diagnosis. — The diagnosis of stone rests upon attacks of 
renal colic, haematuria, and the discovery of concretions in the 
urine. In pyelitis or nephritis the presence of a stone in the 
kidney may be suspected, even if no attacks of renal colic have 
occurred, from the persistent character of the localized pain in 
the kidneys, aggravated by motion, and from the presence of 
blood in the urine. Stone in the bladder gives rise to uneasi- 
ness, pressure and pain about the neck of the bladder; the urine 
is alkaline. 

Attacks of renal colic may resemble intestinal colic, but the 
latter, though possibly very severe, lacks the agonizing char- 
acter of renal colic ; there is wanting the frightful pain in the 
flank, the urinary sj'mptoms, the retraction and tenderness of 
the testicle. Intestinal colic yields more readily to measures in- 
stituted for its relief. Hepatic colic is associated with dilata- 
tion of the gall-bladder and jaundice. The pain from perforat- 
ing appendicitis is characterized by localized extreme tender- 
ness which is not frequent in renal colic; on the other hand, 
there is no haematuria. Nephralgia, frequently associated with 
movable kidney, has no haematuria and no passage of stone. 

While it is not possible to determine in advance the character 
of the calculus which is the cause of so much suffering, it is 
well to remember that the smooth surface of a uric acid calcu- 
lus renders its presence less painful than that of the rough oxa- 
late of lime concretion, which causes intense radiating pains, or 
of the phosphatic calculi which are said to give rise to even more 
intense suffering. It should also be borne in mind that the 
former occur in acid, while phosphatic calculi occur in alkaline, 
urine. 

Prognosis. — An attack of renal colic is without danger to life, 



NEPHROLITHIASIS. 1243 

save in rare complications, as impaction of a calculus in the 
ureter, and many attacks may be borne without permanent ill 
results. In case of anuria the condition is necessarily serious, 
but recoveries are on record after complete suppression of urine 
for many (even twenty) days. The danger arising from reten- 
tion of a large stone in the kidney has been pointed out ; the 
fact that a calculus thus retained for a long time has caused no 
inconvenience cannot be considered a proof of continued im- 
munity ; the circumstances must rather be considered a stand- 
ing menace to health and life. An immense number of stones 
may be passed with no apparent failure of health. Calculi 
having been passed, and new stones not forming, complete re- 
covery takes place. 

Nephrolithiasis is intensely chronic, and a perfect cure is the 
exception rather than the rule. 

Treatment. — The management of an attack of renal colic 
consists of the use of the hot bath, local application of hot 
poultices, or of cloths wrung out of hot water and changed 
rapidly. Morphine should be given hypodermically, at once, 
and until narcosis is well established inhalations of chloroform 
and ether should be employed. The writer has passed through 
two attacks of renal colic without taking morphine, and is pre- 
pared to affirm the extreme folly of such a course. At the same 
time, hot drinks should be given freely. It is stated that inver- 
sion of the body is often followed by immediate relief, the cal- 
culus dropping back into the renal pelvis. C. A. Walton claims 
that the introduction of a sound or catheterization during re- 
nal colic first, but only for a moment, increases the pain, but is 
followed by permanent relief in a few minutes, and sometimes 
at once. The acute attack having passed, the patient should 
be kept quiet until he has thoroughly recovered, and must be 
cautioned ever after to avoid violent physical exertion, espe- 
cially heavy lifting. The kidneys should be freely flushed, and 
to that end pure distilled water should be used. It is well to 
drink daily between meals from two to three pints of distilled 
■water, to which bicarbonate or citrate of soda in small 
amounts may be added. Wood and Fitz highly recommend the 
following formula : 

5*, Lithii benzoat., 

Lithii bicarbon., . . aa grs. xv. 

Potassii bicarbon., grs. xx. 



1244 DISEASES OF THE KIDNEYS AND BLADDER. 

Aquae acid, carbonici, 0. I. 

Misce et dispensa in siphone. 

Of this, two pints are to be taken daily. 

The diet is that of the early stage of gout. 

It is still an open question whether, or not, the so-called sol- 
vents are of the slightest value. Experiments made with piper- 
azine outside of the body justify the hope that it has some 
virtue as a solvent, and it is the fashion now to prescribe it for 
this purpose, fifteen grains daily in divided doses in an aqueous 
solution, continued for a considerable period of time. Hale 
states that boro-citrate of magnesia in doses ranging from five 
grains of the crude salt to five grains of the first decimal tritur- 
ation given in large quantities of pure water will disintegrate 
phosphatic and calcareous stone in the kidneys. It is possible 
that the persistent use of alkaline solvents, whether piperazine 
or potassium citrate, may result in a deterioration of the gen- 
eral health and a deposit of phosphates about the calculus. 

Whenever there is proof that the presence of a calculus in the 
kidney is producing serious effects upon that organ, operative 
interference, as extraction of the stone or removal of the af- 
fected kidney, must not be postponed too long. 

The exhibition of the " homoeopathically " indicated remedy 
for the relief of renal colic is not only a waste of time but in- 
volves an inexcusable misapplication of a meritorious principle. 
No remedy can possibly affect curatively the distress caused by 
the pressure of a rough calculus in the ureter slowly forcing its 
way downward toward the bladder, and which will not cease 
until the instant this passage has been accomplished. It may 
be urged that remedies like Cantharides may and do control 
special symptoms, such as the urinary irritation, or that Taba- 
cum may relieve the deathly nausea and sickness which so often 
result from the intense suffering ; but prescribing of this sort 
bears slight resemblance to the selection of a remedy from the 
totality of symptoms and for the purpose of curing a morbid 
condition. On the other hand, the properly selected remedy, 
exhibited at the proper time, ma3 r accomplish much toward 
bettering the general condition of the patient and toward so 
regulating the functions of the system that the danger of cal- 
culus-formation shall be lessened and possibly removed Thus 
Lycopodium is to be considered when the amount of urine is 



TUMORS OF THE KIDNEY. 1245 

scanty, and there is constantly present a red, sand-like deposit. 
There may be considerable dysuria and vesical irritation. Its 
value in the so-called uric acid diathesis has been abundantly 
demonstrated. It is thought to have a preference for the right 
kidney. — Berberis in provers has caused marked urinary symp- 
toms, nearly always with deposits of mucous sediment, con- 
taining a bright-red mealy substance. It has also pain, sore- 
ness and burning in the urinary tract, with pain extending into 
the hips and loins. Clinical experience has proved its value in 
the lithic diathesis. — Benzoic acid is useful in gouty conditions ; 
the sediment in the urine is rich in phosphates. — Oxalic acid 
has marked irritation of the bladder; " urine passed in the 
morning and evening very acid, deposits of numerous crystals 
of uric acid, indications of oxalate of lime in the milky white 
sediment. Urine loaded with enormous crystals of oxalate of 
lime, containing also some blood disks." Pain in the renal re- 
gion, in some provers extending into thigh and leg. — Ocimum 
was used by Dunham for the uric acid diathesis, with large de- 
posits of red sand, particularly if the patient was subject to 
pain in the ureters. Turbid urine with a white and albuminous 
sediment, cramping pain in the kidneys, renal colic and vomit- 
ing ; urine red, with brick-dust sediment or discharge of large 
quantities of bloody urine or thick, purulent urine. 
Consult also Arsenic, Asparagus, Nux vomica, Sarsapa- 

RILLA, UVA URSI, PAREIRA BRAVA. 

TUMORS OF THE KIDNEY. 

Tumors of the kidney are benign or malignant. The former 
(fibroma, lipoma, angioma, myxoma, adenoma) are of slight 
clinical importance; the malignant growths are sarcoma (in- 
cluding myosarcoma) and carcinoma. Both cancer and sar- 
coma may be primary or secondary. If primary, they are 
rarely found at birth, more often early or late in life, and more 
frequently in males than in females. 

The symptoms of malignant disease of the kidneys are rarely 
well defined. Frequently there is no pain from first to last ; if 
present, it is of a dragging character, usually felt in the flank, 
and radiating down the thigh. Haematuria is an early symp- 
tom ; it may be intermittent or continuous, slight or sufficiently 
copious to prove fatal. The blood escapes fluid or clotted, and 



1246 DISEASES OF THE KIDNEYS AND BLADDER. 

often constitutes perfect blood casts of the pelvis and ureters, 
which are of great diagnostic value. The passage of these 
clots may be very painful. Emaciation is progressive, rapid 
and pronounced. The recognition of the tumor is important 
and can usually be accomplished by bimanual palpation. If 
small, especially on the right side, it may be freely movable ; 
large tumors may be slightly movable, but oftener are fixed. If 
its growth has been attained rapidly, a degree of fluctuation 
may be observed and the aspirator used to determine the char- 
acter of its contents. The shape of the tumor and its location 
in the lumbar region ma3 r suggest its identity. It is overlapped 
by both liver and spleen, with coils of intestine separating it 
from these organs. The colon crosses the tumor and may 
usually be recognized without difficult}-, establishing an impor- 
tant diagnostic point. 

Diagnosis. — Enlarged spleen is recognized by its mobility, 
the distinctness with which its edges are outlined, and the pres- 
ence of the characteristic notch or notches. Tumors of the 
liver and distended gall-bladder are freely movable and are not 
overlaid by the colon ; usually, in renal tumor, a zone of reso- 
nance exists between its upper margin and the ribs. The dif- 
ferentiation between retroperitonaeal sarcoma and renal dis- 
ease, in children, is practically impossible when the tumor is 
large ; of the two, the sarcomatous tumor is less movable. 

Progressive and marked cachexia, with no apparent cause, 
and severe pain in the renal region suggest the possibility of 
renal cancer, even if there is no tumor and the urine appears 
normal ; hematuria, however, is almost sure to occur sooner 
or later. 

Prognosis. — Although involvement of only one kidney makes 
extirpation a practical operation by, at least, prolonging life, 
the prognosis is invariably hopeless, death usually occurring 
within a year after recognition of the disease. Death takes 
place from exhaustion or from rupture of a blood-vessel, or 
from gangrene of the tumor. 

Treatment consists of measures for the relief of pain, nour- 
ishing diet, and endeavors to render the patient comfortable. 
Remedies must be selected upon symptomatic indications. Ex- 
tirpation of the kidney for malignant disease has proved a very 
unsatisfactor}- operation, with immediately fatal results in 
nearly one-half of all the cases. 



CYSTS OF THE KIDNEYS. 1247 

CYSTS OF THE KIDNEYS. 

Cysts may occur in an otherwise healthy kidney or when the 
kidney itself is diseased. They are nearly always bilateral, but 
one kidney is pretty sure to be larger than the other. They 
may be solitary or multiple. The former vary in size from that 
of a marble to a small orange, but may become sufficiently 
large to constitute an abdominal tumor capable of causing 
mischief by mechanical interference. Multiple cysts may occur 
in very large numbers ; they are usually small, but may fuse and 
constitute several large cysts, filled with a serous, sometimes 
colloid, fluid containing albumin, cholesterine, triple phosphates, 
fat drops, traces of blood, rarely urea or uric acid. Multiple 
cysts are a feature of chronic fibrous nephritis. Of especial in- 
terest is the congenital cystic kidney in which the kidney is 
largely represented by a great mass of small cysts, containing 
a thin, clear or turbid, occasionally dark red fluid in which are 
found albumin, urinary salts, cholesterine, blood, and fat. The 
kidney is much enlarged, not infrequently weighing from six to 
eight pounds, and when occurring in the foetus may materially 
interfere with labor. In rare cases cystic disease in the kidney 
is associated with cysts in the liver and, sometimes, spleen. The 
real cause of the cystic formation is not known; it originates 
in a dilatation above an obstructed point in some part of the 
uriniferous tubules or at their point of origin in the Malpighian 
bodies. In congenital cystic kidney (multilocular cystic kidney) 
the fault undoubtedly lies in defective development. 

The symptoms of cystic kidney are necessarily vague. As 
stated, cystic formation may exist in an otherwise normal kid- 
ney, and unless sufficiently large to constitute a tumor of con- 
siderable size, the presence of which alone must disturb other 
organs, it may cause no symptoms whatever. In other cases 
the symptoms are those of cirrhotic kidney, with arterial ten- 
sion and hypertrophy of the left ventricle. Or cystic kidney 
may exist indefinitely without being suspected, when suddenly 
symptoms of chronic Bright's disease develop ; an exact diag- 
nosis may be difficult even then. There may be a sudden at- 
tack of uraemic poisoning or fatal heart failure. The congenital 
form usually results in death of the foetus in utero or soon 
after birth. Exceptionally the child may reach mature years, 



1248 DISEASES OF THE KIDNEYS AND BLADDER. 

with the strong probability that sooner or later the difficulty 
will become a source of grave trouble. 

The diagnosis rests upon the presence of a bilateral tumor in 
the lumbar region, with copious discharge of abundant and al- 
buminous urine of low specific gravity. 

Treatment, medicinal or surgical, has proved entirely unsat- 
isfactory. 

PERINEPHRIC ABSCESS. 

Suppuration of the connective tissue surrounding the kidneys 
rarely occurs from exposure to cold, but is nearly always the 
result of an injury (blow, wound) or of extension of inflamma- 
tory and suppurative processes from neighboring organs (intes- 
tines, pleura, caries of the spine, abscess of liver, etc.) or of in- 
flammation of the renal pelvis, kidney or ureter. It is more fre- 
quent in adult life, but is occasionally seen in children, usually 
as a sequel of some one of the exanthematous fevers. 

Symptoms. — The onset of the disease may be insidious, in 
view of its association with primary affections which have 
dairy fever and symptoms likely to mask for a time inflamma- 
tion extending into the connective tissues about the kidney. 
The formation of pus, however, is marked by symptoms which 
may not be overlooked. There is pronounced rigor, followed 
by irregular fever, with a temperature often rising to 104° or 
105°, and profuse sweating. The pulse is rapid, bounding or 
feeble. There is furred tongue, loss of appetite, constipation 
and, when not sweating, hot, dry skin. Pain is slight or even 
absent in exceptional cases. Usually there is severe pain in the 
lumbar region, with aggravation from motion or pressure. It 
may be referred to the region of the hip-joint and extends into 
the thigh and testicle ; the latter may be retracted. The pa- 
tient lies with flexed thighs and finds it painful and difficult to 
adduct the thigh ; when walking, he seeks to throw his weight 
upon the unaffected side and assumes a stooping posture. The 
urine is clear unless the kidney or renal pelvis is primarily in- 
volved. The tumor is at first hard, then develops deep fluctua- 
tion, which eventually becomes superficial. The pus cavity 
formed is usually large and extensive, and may extend from the 
level of the liver and spleen to the iliac fossa, and far enough 



PERINEPHRIC ABSCESS. 1249 

forward to cause protrusion of the abdomen. The abscess 
opens externally by ulceration, or burrowing of pus may take 
place, an exit being found in the groin or at Poupard's liga- 
ment ; or there may be perforation with rupture into the intes- 
tine (colon or duodenum), bladder, vagina, renal pelvis, perito- 
neal or pleural cavity. The pus usually is offensive, and may 
have a distinctively faecal odor. Its evacuation is followed by 
rapid fall of temperature and general improvement. In some 
cases gangrene and sloughing occur. 

Diagnosis. — Perinephric abscess is recognized by the existence 
of a deep-seated induration in the immediate neighborhood of 
the kidney on the affected side, between the last rib and the 
crest of the ileum. Bimanual examination rarely fails to re- 
veal the presence of a distinct tumor. The constitutional 
symptoms indicative of pus formation are easily recognized, 
and fluctuation is in most cases readily detected. The use of 
the aspirator for diagnostic purposes suggests itself. In child- 
hood hip-joint disease may be suspected, especially so since the 
pain is frequently referred to the knee ; but in perinephric ab- 
scess there is no localized fulness and tenderness over the hip- 
joint and, usually, the pain is higher. 

Prognosis. — The disease runs a fairly rapid course, from a 
fortnight to a month ; it must always be considered very seri- 
ous. The outlook is favorable when the abscess has burst out- 
wardly or in such a way internally that it has completely emp- 
tied itself and allows of free drainage Even when such is the 
case, however, much depends upon the character of the pri- 
mary disease, the vitality of the patient, and the care he can 
have. If perforation does not take place, there is great danger 
of a fatal issue from blood poisoning. If recovery takes place, 
the destroyed tissue is largely replaced by the extensive forma- 
tion of cicatricial tissue. Death results from exhaustion, blood 
poisoning, or amyloid degeneration. 

Treatment. — The patient's strength must be sustained by 
generous diet and the judicious use of stimulants. The pre- 
sence of pus demands early, free, and permanent drainage ; for 
this purpose a free incision is unavoidable. The use of such 
remedies as Arsenic, Chininum arsen., Silica, Hepar sulph., 
and others which stand in close relation to suppurative pro- 
cesses, at once suggests itself. 
79 



1250 DISEASES OF THE KIDNEYS AND BLADDER. 

DISEASES OF THE BLADDER. 

CYSTITIS. 

Etiology . — Cystitis or catarrh of the bladder is a common 
affection, due to any one of a large number of possible causes. 
It not infrequently occurs in the course of infectious diseases, 
the noxious material affecting the entire urinary tract, the re- 
sult of efforts at elimination made by the kidneys ; here belong 
typhoid fever, acute articular rheumatism, influenza, erysipelas, 
small-pox, etc. Many cases result from extension of inflamma- 
tion from neighboring parts, as the urethra, rectum, uterus, 
vagina, or peritonaeum ; thus, gonorrhoeal urethritis, espe- 
cially in women, very frequently extends into the bladder. The 
extension downward of an existing pyelitis belongs here. Other 
factors are : the presence of a foreign body (stone) ; injuries 
from the use of some instrument or from the prolonged pres- 
sure caused by a faecal mass, pessary or, occasionally, foetal 
head during labor ; the action of certain drugs which act as ir- 
ritants to the urinary mucous membrane, i. e. turpentine, 
cubebs, cantharides, copaiba, etc. ; the direct irritation caused 
by the presence in the bladder of the strongly concentrated 
urine found in gouty persons. Not infrequently cystitis arises 
from the introduction of a dirty or infected catheter or 
bougie. Partial retention of urine, due to prostatic enlarge- 
ment or defective muscular contraction or imperfect closure of 
the sphincter, results in the formation of carbonate of ammo- 
nia, which is very irritating to the bladder and favors the devel- 
opment of bacteria. Exceptionally cystitis is due to taking 
cold. 

Morbid Anatomy. — The mucous membrane is swollen, re- 
laxed, of bright-red or deep-red color, and covered with a thick, 
slimy, grayish, muco-purulent secretion. The tops of the rugae 
are in part denuded of their epithelium, and pus and loose cells 
are found in the sulci between the folds. If the inflammation 
be more severe, the swelling of the mucous membrane is more 
pronounced, the destruction of its epithelium more extensive, 
and the submucous tissues are thickened. Occasionally large 
parts of the lining membrane are thrown off, especially in C3 r s- 
titis due to retention or over-distension. 

If croupous or diphtheritic, fibrinous clots are present, with 



DISEASES OF THE BLADDER. 1251 

ecchymoses, ulceration, and superficial necrosis, especially abun- 
dant at and near the neck of the bladder and upon projecting 
folds of the vesical mucous membrane. It is usually seen in 
patches of varying size, very rarely covering the entire surface. 
Suppuration may occur in the submucous connective tissue or 
between the muscular and serous coats, frequently resulting in 
the formation of small abscesses, more often a single abscess, 
located near the neck and eventually discharging into the blad- 
der. In rare cases the pus is diffused through the connective 
tissue of the coats of the bladder. Gangrenous disorganization 
sometimes takes place, in which case there is extensive destruc- 
tion of mucous tissue, possibly involving the deeper structure ; 
the mucous membrane appears dark, charred, gangrenous, and 
the submucous connective and muscular tissues are softened 
and infiltrated with foul, bloody pus. Ulcers of varying shape 
are found, more often about the neck of the bladder. They 
sometimes are circular, with well-defined margins, sometimes 
irregular in outline, with ragged borders ; they may perforate 
into the abdominal cavity or adhesive inflammation may take 
place. In chronic cystitis the mucous membrane appears slate- 
colored, grayish -black, and may be found incrusted with 
urinary salts, especially ammonio-magnesic phosphate; the 
urine contains pus or muco-pus. 

Symptoms. — Acute cystitis may begin with or without chill 
and fever. Pain is usually one of the first and most persistent 
symptoms. It is centered in the region of the bladder, and may 
involve the perinaeum and rectum. Its greatest intensity is as- 
sociated with the act of voiding urine, and it is somewhat re- 
lieved when the bladder has been emptied. There is a torment- 
ing urging to pass urine every few minutes, the act being char- 
acterized by intense vesical tenesmus or strangury, the patient 
straining with all his might in spite of the intense pain caused 
by the effort ; only a small amount of urine is passed at a time, 
often followed by a few drops of blood. In some cases painful 
reflex spasms of the sphincter result from the irritability of the 
mucous membrane. The urine is almost normal in amount 
during the twenty-four hours ; it usually looks clear, but de- 
posits a copious sediment containing pus, bladder epithelium, 
and bacteria ; in addition to these, there are shreds of necrotic 
tissue if the cystitis is diphtheritic or gangrenous, and blood 



1252 DISEASES OF THE KIDNEYS AND BLADDER. 

corpuscles and blood-clots if there has been haemorrhage. Fre- 
quently the urine is high-colored ; it may be acid or alkaline, 
sometimes neutral, in reaction. If not examined until after it 
has stood for some time, it may^ be strongly alkaline and of de- 
cided ammoniacal odor, readily depositing the coffin-lid crys- 
tals of ammonio-magnesic phosphate and urate of ammonia 
crystals. The so-called " mucous cloud " in the urine is noticed 
in mild cases, and consists of a grayish sediment which holds 
particles of slime, polynuclear leucocytes, cells of vesical epithe- 
lium, occasionally red blood corpuscles, and often a multitude 
of bacteria. The sediment of the urine in severe cases frequently 
is very viscid and may be drawn out into long threads, because 
of its richness in albumin from the solution of abundant pus 
corpuscles and epithelium in the alkaline urine. Fever usually 
accompanies even a moderately severe cystitis. It may be 
very high and even threatening when there is extensive sup- 
puration or necrosis, or when the kidney is involved, or when 
there is extension of the inflammation into pericystic tissues. 
Such cases are often characterized by severe nervous symptoms, 
as headache, dizziness, nausea, and may terminate in delirium, 
somnolency- and stupor. 

The formation of an abscess is indicated by a localized indur- 
ation with great pain and tenderness, which may be easily de- 
tected by examination per rectum. The abscess may break, 
with immediate relief of symptoms, or cause peritonitis by ex- 
tension of inflammatory action. 

In mild cases of acute cystitis the fever, pain and tenderness 
grow less in a few days, the urine becomes normal, and recov- 
ery takes place early. The more protracted the course, the 
more serious the outlook and the more doubtful the prognosis, 
especially in case of extension of the disease to the kidneys or 
adjacent fibrous tissue. Chronic cystitis is characterized by 
increased frequency of urination and, often, pain. The urine is 
cloudy and contains some pus cells. There may be some supra- 
pubic uneasiness. The general health does not suffer, save in 
unusually severe and prolonged cases or unless associated with 
a serious primary disease, as stricture or calculus. Henry- 
Thompson states that the "well-known glary mucus which is 
deposited so abundantly from the urine in some cases, in elderly 
people almost invariably, appears only in those whose urine is 



CYSTITIS. 1253 

abnormally retained, through atony of the vesical walls, or in 
consequence of enlarged prostate, or as the result of saccula- 
tion of the bladder." Chronic cystitis frequently proves incur- 
able, since often it depends upon diseases which are beyond the 
reach of help, as paralysis of the bladder from affection of the 
spinal cord. 

Treatment. — The patient should be put to bed at once and 
kept there until well ; by this means alone the danger of a pro- 
tracted attack is greatly lessened. The hips should be slightly 
raised and the knees befit over a pillow. The bowels should be 
opened by a hot enema or Epsom salts. The diet must be light 
and non-irritating; milk may be used freely or exclusively. 
Spices, alcoholic stimulants, etc., are forbidden. Pure water 
should be drunk freely to wash out the bladder. Hot decoction 
of triticum repens, or linseed tea, or barley water are excellent. 
The patient should be directed to restrain as long as possible 
the desire to empty the bladder in order to avoid the pain and 
the additional irritation caused by the effort ; to aid in this, 
suppositories containing one grain of the extract of opium and 
one-fourth grain of the extract of belladonna are useful. If the 
urine is strongly alkaline or ammoniacal, drinks containing 
boric or benzoic acid should be used ; if strongly acid, drinks 
containing alkalies are useful. Much benefit may be derived 
from hot sitz baths taken several times a day, and from the ap- 
plication over the bladder of cloths wrung out of hot water, to 
which hops may be added. Catheterization has been strongly 
recommended, but it involves so much pain and may so readily 
increase the existing irritation that it should only be practiced 
when residual urine is in the bladder. The remedies chiefly 
used by the dominant school are : chlorate of potash, in watery 
solution, from forty to seventy-five grains per day, never on 
the empty stomach; salicylic acid, from thirty to sixty grains 
per day, in ten-grain capsules ; arbutine, the active principle of 
uva ursi, from forty to sixty grains per day in a watery solu- 
tion, or the decoction of uva ursi. 

The treatment of chronic cystitis demands above all the re- 
moval of residual urine by catheterization and frequent wash- 
ing out of the bladder. For the former, a soft rubber catheter 
should be used, kept in a weak bichloride solution and carefully 
cleansed in hot water before it is put away. If the case is se- 



1254- DISEASES OF THE KIDNEYS AND BLADDER. 

vere, or if there is much pus and mucus, or the urine is ammoni- 
acal, injections should be made into the bladder; these will re- 
move an}^ urine still retained in pouches, will cleanse the walls 
of the bladder, wash away sediment, and aid in restoring the 
lost natural contractile power of the organ. When injections 
into the bladder are made, the urethra should be disinfected 
with a weak bichloride solution (1:4000), then warm water 
should be introduced into the bladder, very slowry and with a 
steady, continuous flow, not more than two or three ounces at 
a time ; this must be kept up until the fluid returns clear. If it 
is desired to use medicated injections, the}- must not be intro- 
duced until the bladder has been thoroughly washed out, and 
must not be allowed to remain in the viscus for more than 
three or four minutes. For this purpose a fountain sy ringe, pro- 
vided with a two-way stop cock may be used. Thus the inflow 
of fluid may be stopped by turning the appropriate cock as 
soon as the patient experiences a sense of distension of the 
bladder; the bladder is then allowed to empty itself, after 
which another injection ma}^ be given, to be repeated until the 
object has been attained. After the bladder has been thor- 
oughly washed, the medicated injection is administered in the 
same manner. The favorite injections are: acetate of lead, 1 
to 1000; permanganate of potash, 1:1000; corrosive subli- 
mate, 1:15000; carbolic acid, 1:500. Solutions of boric or 
salicylic acid have proved useful. Many practitioners still ad- 
vocate the superiority of nitrate of silver in M? to 2 per cent, 
solution ; if the strong solution is employed, it must be used 
very carefully, beginning with the weaker solution and in small 
amount. Many cases have derived material benefit from drink- 
ing copiously of a decoction of triticum repens, boiling from two 
to four ounces of the root in a pint, or more, of water. The 
patient must always be warmly clothed, wearing woolen un- 
derwear both summer and winter. 

Treatment of necessity embraces attention to the primary 
disease, as the presence of stone or stricture, and the intelligent 
management of a paralytic condition of the bladder which may 
be responsible for the existence of the vesical catarrh. 

Therapeutics. — Aconite. From exposure to cold. High and 
characteristic fever. Burning at the neck of the bladder when 
urinating and after urinating. Severe tenesmus and burning. 



CYSTITIS. 1255 

Urine scanty, dark and hot. Retention of urine in infants; they 
reach with their hands to the genitals and cry out. — Apis mel- 
lifica. After poisoning with cantharides, camphora and 
other irritants. Great vesical irritability ; when urinating, 
stinging pain and vesical tenesmus. Urine high-colored, rarely 
bloody, sometimes retained. — Belladonna. Frequent painful 
urination ; great sensitiveness of the bladder and hypogastrium 
to touch and jar; urine hot, burning; at first clear, it becomes 
turbid on standing, then deposits a red, bran-like sediment. In 
very acute cases, after Aconite has failed to bring about im- 
provement. — Cannabis sativa. In cystitis associated with 
gonorrhceal urethritis. Burning, biting pain from the urethra 
into the bladder when urinating ; frequent urging ; urine scald- 
ing and bloody, great irritability of the vesical sphincter. — 
Cantharides. Frequently indicated ; it covers all the symp- 
toms of severe inflammation of the bladder. Constant urging 
to urinate, with much straining, the urine passing drop by 
drop, or in a thin stream, with frightful burning and 
strangury. Severe burning, scalding pain at the vesical neck, 
extending to the glans penis or testicles, which are retracted, 
or into the perinaeum and rectum. Urine scanty, high-colored, 
bloody, albuminous, containing shreds of membrane. Useful in 
the severest forms of cystitis, with violent constitutional symp- 
toms, as distended, hard, painful abdomen, nausea and vomit- 
ing, uncontrollable thirst, high fever. He cannot stand on his 
feet for a moment without intense urging to urinate. In some 
cases the patient is tormented by violent and painful erections. 
In cases connected with renal inflammation. — Chimaphila. 
" Catarrh of the bladder, both acute and chronic, especially in- 
dicated when the urine is offensive, turbid, containing ropy or 
bloody mucus, and depositing a copious sediment, with burning 
and scalding during micturition and straining afterwards ; it is 
very difficult to begin to urinate, the patient strains a great 
deal, urine sometimes fetid ; concomitants of chronic cystitis." 
(T. F. Allen.)— Copaiva. Great difficulty in making a little 
water; dysuria ; much urethral inflammation and soreness and 
swelling and soreness of the urethral orifice. Constant urging 
to urinate. Bloody urine. Urine smells of violet. Gonorrhceal 
urethritis. More frequently useful in chronic cases. — Equisetum. 
Pain and tenderness in the region of the bladder, with sense of 



1256 DISEASES OF THE KIDNEYS AND BLADDER. 

painful distension. Frequent and painful urging to urinate, 
worse after the urine has passed. Urine contains some mucus 
and blood.— Eupatorium perfoliatum. Much backache, in the 
renal region; sore pain all along the spine, from below upward ; 
constant urging to urinate, with biting and burning in the 
urethra. — Mercurius. Of gi-eat value when associated with 
renal disease. Burning and tenderness ; pain in the back ; burn- 
ing after urinating; urine may contain pus, blood, shreds. In 
diphtheritic cystitis (Merc, cynat.; Merc, corrosiv.) with vesi- 
cal symptoms of sufficient severity to suggest Caktharides. — 
Nux vomica. In subacute and chronic cases. The bladder is 
quite irritable ; the efforts to urinate are frequent and painful 
from strangury. The amount passed is scanty ; burning in the 
urethra when urinating ; contractive pain in the urethra after 
urinating ; urine high-colored, sometimes bloody ; of great value 
in chronic cystitis depending upon paralytic trouble. — Pulsa- 
tilla. In mild forms. During pregnancy or associated with 
prostatic enlargement or suppressed gonorrhoeal discharge. 
Spasmodic pains extending to the hips and thighs. Sensation 
of distension and fulness in the bladder; slight or no pain in the 
urethra. Profuse mucous sediment in the urine. — Terebin- 
thixa. When associated with inflammation of the kidneys re- 
sulting from an acute infectious disease. Much dull burning 
pain in the region of the kidney, extending into the bladder; ves- 
ical tenderness ; the urine deposits a thick, slimy sediment and 
contains much blood. Tenderness of the hypogastrium. 

Hale states that "two of the best palliatives of the agonizing 
pain in cystitis are corn-silk (Stigmata maidis) and Hydran- 
gea in doses of from ten to twenty drops of the tincture every 
hour or two." 

Chronic cystitis. — In spite of the fact that mechanical treat- 
ment, as above described, is of the greatest importance, the ex- 
hibition of the proper remedy may materially aid in curing the 
case or, if that is impossible, in rendering the patient's condition 
much more comfortable than it otherwise would be. Remem- 
bering the varied and serious character of the primary affec- 
tion, it is evident that a list of possibly indicated remedies 
would be large. The following are the most important : Bex- 
zoic acid (benzoate of ammonia). Offensive urine with granu- 
lar mucus and phosphates in the sediment ; urine scanty, dark- 



ENURESIS. 1257 

red or brown, bloody, ammoniacal, of foul odor ; rheumatic 
tendency. — Conium. Partial paralysis of the bladder; the 
urine flows by fits and starts, easier when standing. — Cubeba. 
Sense of cutting and constriction while urinating ; hematuria ; 
in women with inflamed urethra, who must urinate every little 
while, with smarting, tenesmus and ropy mucus. — Dulcamara. 
From cold. Nephritis. Urine milky, thick, turbid, slimy, voided 
with burning in the urethra. Sometimes vesical tenesmus ; oc- 
casionally involuntary voiding of urine. — Epigea repens. 
"Dysuria; tenesmus vesicas after micturition; burning in the 
vesical neck "when urinating; bloody sediment ; urine contains 
mucus and pus." (Doughty.)— -Eucalyptus. An excellent 
remedy. The urine is scanty and foul-smelling, with copious 
muco-purulent sediment. Burning when urinating. "Even use- 
ful when there is urinary fever, with chills in the afternoon, 
hectic and night-sweats." (Hale.) — Hydrastis. Urine smells 
as though decomposed ; thick, ropy mucus in the urine.— Ly- 
copodium. Milky deposit of bad odor. Uric acid diathesis; 
gravel ; retention of urine ; in children. — Pareira brava. Use- 
ful in acute, but especially in chronic, cystitis. Much violent 
straining, with scalding in the urethra. Urine ammoniacal and 
contains a great deal of thick, white mucus. — Populus tremu- 
loides. Vesical catarrh of old people, with much tenesmus, 
urethral soreness and tenderness, with scalding when passing 
urine; urine contains mucus and pus. — Uva ursi. "Frequent 
urging, with severe spasm of the bladder, burning and tearing 
pain ; urine contains blood and tough mucus, which can be 
rolled out of the vessel in large masses." (T. F. Allen.) 

Consult also: Nux vom., Pulsatilla, Copaiya, Chima- 
phila, Arsenic, Colocynthis, Calcarea carbon., Kali 

BICHROMICUM, LaCHESIS, SEPIA, SULPHUR. 

ENURESIS (Incontinence of Urine). 

Inability to retain the urine is a common affection in young 
children, before the age of puberty ; it is not infrequent in 
women, but rare in men. In a general way it depends, upon 
either weakness of the sphincter, possibly congenital, or upon 
an abnormal irritability of the detrusor. Special causes are : 
paralysis of sphincter or compressor urethrae muscle from cere- 



1258 DISEASES OF THE KIDNEYS AND BLADDER. 

bral or spinal lesion; enlargement and separation of the median 
lobe of the prostate, opening the meatus internus ; injuries to 
the vesical neck or urethra, such as may occur in the course of 
operations or from a fall or blow ; loss of substance of the ves- 
ical neck from ulceration ; hyperesthesia of the bladder or of 
parts of it and of the prostatic urethra from acidity of the 
urine or from sympathy in affections of the kidneys, rectum, 
vagina, uterus, or glans penis. To the latter class belongs the 
irritation often found in boys who have a redundant or adher- 
ent prepuce, particularly when the preputial orifice is con- 
tracted. In children, nervous affections (as chorea or epilepsy), 
intestinal worms, masturbation, general irritability of the ner- 
vous S} r stem and conditions which result in polyuria are com- 
monly associated with incontinence of urine. 

In children the affection almost always takes the form of 
wetting the bed at night. Usually this occurs toward morning, 
after a considerable amount of urine has accumulated in the 
bladder ; but it may occur at any time after the child has fallen 
into a sound sleep, and rarely arouses the patient. In severe 
cases the accident may take place during the day, the little pa- 
tient, if a desire to urinate is experienced, being unable to reach 
a place where he can relieve himself. In adults, especially in 
women, no trouble is experienced while the patient remains per- 
fectly quiet ; but a varying amount of urine escapes upon a 
sudden movement or upon coughing or sneezing. In other 
cases the patient has simply lost volition, the bladder empt\-- 
ing itself when full. In the worst form, caused by mechanical 
causes or organic lesion, the urine escapes in a continual 
stream, as fast as it reaches the bladder. 

Children nearh' alwaj's recover as the}' grow older. The re- 
moval of the cause or intelligent medication usually effect a 
prompt cure. Exceptionally the condition persists beyond 
puberty, and then becomes a source of great annoyance and a 
serious affliction, especially to young girls ; in these cases the 
trouble may cease after marriage. In adults the prospect of 
cure is much less encouraging than in children, since the cause 
of the affection is usually deep-seated and beyond reach. 

Treatment.— In children attention must be paid to the diet, 
excluding from it a too generous allowance of sweets and acid 
fruits. The evening meal should be light. The child should be 



ENURESIS. 1259 

taken up occasionally in the night and placed upon the cham- 
ber. If troubled with "worms," the parasites should be re- 
moved by proper treatment. The clitoris of a little girl, if 
bound down or tightly hooded, must be placed into a normal 
condition and circumcision be performed upon boys if occasion 
for it exists. A normal life in the open air will prove of mate- 
rial help to adults and children. Electricity may be very help- 
ful, but as yet much difference of opinion exists concerning the 
best method of applying it and the result to be expected. If 
there is weakness of the vesical center in the spinal cord, gal- 
vanism is passed from the lumbar spine to the perinaeum ; when 
enuresis results from irritability or excitability of the detrusor 
muscle or from weakness of the sphincter, the faradic current, 
applied in the same manner, is preferable. Jacobi prefers to 
introduce one electrode from an induction apparatus into the 
rectum, placing the other, the sponge electrode, on the raphe 
perinei ; passing a weak current, just bearable, for five to ten 
minutes, repeating daily for four to six weeks. "In reality it is 
probably better to combine the two forms of electricity. The 
galvanic current should be used not as a sedative, but to im- 
prove the nutrition of the sphincter muscle. Then — but coinci- 
dently — the muscle should be stimulated to contract by the 
faradic current, and thus exercised in the performance of its 
function. A daily seance is necessary, preferably at bed-time" 
(Jacobi). Many cures with the homceopathically indicated 
remedy have been reported, the number of remedies employed 
embracing a long list, because a relation, homceopathically, to 
the primary cause is a necessary condition to a cure. Thus, if 
enuresis is of purely nervous origin, Chamomilla, Gelsemium, 
Ignatia, Nux moschata, Asa fostida, Hyoscyamus, Phos- 
phorus, Phosphoric acid and others of the same class are to 
be studied ; if the result of debility, China, Arsenic, Ferrum 
phosphoricum, Iodine and Sulphur will be specially import- 
ant ; if connected with a lithaemic tendency, this fact will point 
to Lycopodium, Benzoic acid, Lithium, Bryonia, Berberis, 
Colchicum, Rhus, Phytolacca.— Belladonna. Sphincter 
paralysis ; dark, offensive urine ; starting and crying out aloud 
during sleep ; irritability of the bladder. — Causticum. Par- 
alytic weakness of the bladder ; urine expelled very slowly and 
incompletely. Enuresis in the early part of the night and dur- 



1260 DISEASES OF THE KIDNEYS AND BLADDER. 

ing the day from the slightest excitement. Involuntary spurt- 
ing of urine when coughing. Paralysis of the bladder after 
labor. — Cina. In children troubled with worms ; wants to uri- 
nate every little while both daj r and night. — Equisetum. Much 
vesical irritation ; incontinence of urine in old men ; "weakness 
of the bladder, dribbling in insane people who will not attend 
to the bladder." — Ferrum phosphoricum. Urine deposits a 
whitish sediment. Child appears weak, backward, does not 
thrive ; complains much of headache ; constantly wets itself. — 
Gelsemium. Paralytic condition of the bladder in children 
after diphtheria, in old people.— Hyoscyamus. Child cannot 
urinate when it wants to do so ; immediately after, involuntary 
escape of urine. Paralysis of the bladder. — Pulsatilla. 
Child of mild, tearful disposition ; averse to, and incapable of, 
severe muscular exercise ; incontinence from weakness of blad- 
der, both day and night ; when walking about or playing ; 
when coughing. — Sepia. Enuresis, especially in the early part 
of the night. The urine deposits a red sediment which adheres 
tightly to the vessel. 



PART XI. 

DISEASES DUE TO ANIMAL 
PARASITES. 



PART XI. 

Diseases Due to Animal Parasites. 



DISEASES DUE TO ANIMAL PARASITES. 

Animal parasites, greatly differing in structure and habits, 
enter the human system and may there become a source of 
more or less serious, even fatal, disease. The larger number of 
these parasites enter the body in the food and drink; they 
may remain in the intestinal canal or migrate to any part of 
the body, and there give rise to constitutional disturbances ; or 
they may infest the skin and, unable to migrate, cause symp- 
toms of a purely local character. 

PARASITIC PROTOZOA. 

The protozoa represent the lowest form of animal life ; sev- 
eral varieties are found in the human body. 

Amoeba?. — Of these, the amoeba coli or dysenterica occurs ex- 
tensively in dysentery ; amoebae have also been found in the 
urine, usually with haematuria, with or without nephritis. 

Sporozoa. — The sporozoa (psorosperms or gregarinidae) are, 
as a rule, parasites of the cell (cystozoa) and are closely related 
to the hsetnatozoa or blood parasites. The coccidium ovi- 
forme, one of the commonest varieties, occurs in rabbits and 
many domestic animals, as cats and dogs, and has been found 
in man. The young amoeboid coccidia enter the mucous mem- 
brane of the intestines and of the bile-ducts, and there encapsu- 
late, developing numerous spores within the capsule ; when the 
capsules break, the spores are set free and either multiply freely 
or make their way to other parts. The mass of capsules, in the 



1264 DISEASES DUE TO ANIMAL PARASITES. 

liver of the rabbit, form whitish nodules throughout the or- 
gan, of the size of a pin's head to a split pea ; those found in 
man in appearance suggest tuberculous nodules. 

The presence of sporozoa in man gives rise to Psorospermia- 
sis, which may be internal or cutaneous. In the former, collec- 
tions of the parasites are found in the liver, spleen, kidne\'S, 
ureters, intestinal mucous membrane, myocardium, pericar- 
dium and in the pleuritic exudations. When found in the ab- 
dominal viscera, there is more or less fever, tenderness over the 
liver and spleen, often with presence of small tumors in the 
liver, nausea, diarrhoea, dry tongue, great nervous prostration. 
When the kidneys or ureters are involved, there is hematuria 
and frequent urination. Cases of internal psorospermiasis 
often prove fatal. 

The cutaneous form is rare, but well authenticated cases have 
been recorded. Among others, two cases were reported in the 
Johns Hopkins Hospital Reports. In one of these the lesion re- 
mained local for nearly eight years, and had been considered 
tuberculosis of the skin. The lymphatic glands finally became 
involved, fever set in, and, later, cough, with purulent expector- 
ation. After death the lungs, adrenals and testes, as well as 
the spleen, the surface of the liver and pleurae, were found 
studded with nodules which appeared tuberculous, all contain- 
ing enormous numbers of the sporozoa. The other case ran a 
rapid course, but presented the same features after death. 
Paget' s Disease of the Nipple and Keratosis follicularis of White 
have been considered of parasitic origin ; but it is thought 
probable that the changes observed are in reality a Iryaline 
metamorphosis of epithelial cells. Speculations of possible par- 
asitic origin are entertained in reference to molluscum conta- 
giosum and epithelioma. 

Infusoria. — Of these, the Trichomonas or Cercomonas homi- 
nis and the Megastoma entericum or Lamhlia intestinalis are 
found chiefly in the intestines under a great variety of condi- 
tions; they have also been seen in the urine, in pulmonary gan- 
grene, in the gangrene of bronchiectasis, and in pleurisy. The 
Trichomonas vaginalis is found in acid vaginal mucus. 

Of the ciliated infusoria the Balantidium coli is often present 
in the large intestine in dysentery. As yet, it is not known 
whether, or not, it is pathogenic ; in carefully observed cases 



HELMINTHIASIS. 1265 

the frequency of the stools was always associated with an in- 
crease of the infusoria in them. 



HELMINTHIASIS. 

This term covers the disturbances caused in man by the pres- 
ence of verminous parasites. 

TAPE-WORMS. 

Tape- worm or taenia belongs to the Cestodes. Several va- 
rieties are known, of which Taenia solium and Taenia saginata 
are the most important. 

Taenia solium (pork tape-worm) is from six to ten or twelve 
feet long, has a round head, not as large as a pin's head, armed 
with a double row of hooklets (armed tape-worm) and pro- 
vided with four suckers. The neck is very narrow, thread-like ; 
as segments (proglottides) form, the neck becomes transversely 
grooved ; the segments, some three feet from the head, are 
square, not elongated. The segments from the four hundred 
and fiftieth downward are mature; they contain both male and 
female generative organs ; pressed between two plates of glass, 
the uterus is easily seen, in the form of a central trunk, with 
eight or ten lateral branches on each side ; a slight projection 
on the border of the segment constitutes the genital opening, 
from -which thousands of eggs may be pressed as an opaque 
fluid. Each egg consists of a hard shell containing a little em- 
bryo armed with six hooklets. The mature segment is about 
one centimetre in length and from six to seven millimetres in 
width. Segments are freely passed with the stool after the par- 
asite has become three or four months old ; as passed, they are 
often misshapen, fused, or perforated. The parasite lives in the 
middle of the small intestine, to which it fastens itself by its 
hooklets. Usually there is but one tape-worm domiciled in the 
intestine ; but several, even many, may exist in the same indi- 
vidual. The worm may float in the intestine, with the head 
uppermost, or may be knotted together in a mass ; if the num- 
ber of parasites is large, and they are knotted, they may fill 
the lumen of the gut. Occasionally reversed peristalsis results 
in masses being vomited up. The eggs, to insure their further 
80 



1266 DISEASES DUE TO ANIMAL PARASITES. 

development, must be taken into the stomach of a mouse, dog, 
sheep, swine or rat ; this done, the shells are digested and the 
embryo set free, passing into various organs (brain, liver, mus- 
cle, even the eye) where the larva or C3 r sticercus is developed ; 
the larva, when swallowed, becomes a tape-worm. 

Taenia solium is comparatively rare in America ; it is very 
common in countries in which pork is used freely, especially 
raw or insufficiently cooked (Germany ; Asia). 

Taenia saginata, the unarmed or beef tape-worm, is com- 
mon in America and in countries where beef is extensively 
eaten. It differs structurally from the taenia solium in the fol- 
lowing: it is larger, measuring from fifteen to twenty 
feet, or more; its head is larger, measuring about two 
millimetres in breadth ; the head is square-shaped and provided 
with four large suckers, but it has no hooklets ; the ripe seg- 
ments are from 17 to 18 millimetres long and from 6 to 8 milli- 
metres in width; the uterus consists of a medium stem, with 15 
to 35 lateral branches, which leave the median stem in pairs ; 
the ova are larger and their shell thicker. The parasite clings 
to the intestinal wall by its suckers ; segments are passed as 
with taenia solium ; they are ingested by cattle, in whose flesh 
they develop into cysticerci ; meat thus infected and eaten, un- 
less thoroughly cooked, causes tape-worm in man. 

Other and rare varieties are : Taenia elliptica or cucumerina 
{Dipylidium caninum), sometimes found in young children and 
infants ; common in dogs and cats ; embryos harbored in lice and 
fleas. Taenia flavo-punctata (Hymenolepsis diminuta), in rats 
and mice ; eggs in insects; found in small children ; only a few 
cases. Taenia nana. Very rare in children. Taenia Madagas- 
cariensis, an Eastern taenia, very rare. 

Bothriocephalus latus or fish tape-worm, from 15 to 25 feet 
long, with club-shaped head with two lateral grooves, no 
suckers, no hooklets ; segments broad and short. Eggs escape 
directly into the intestine and are further developed in the wa- 
ter ; they are swallowed by pike, salmon and other fish ; the 
mature worm grows in persons who eat the fish "raw or im- 
properly cured. Common along the Baltic, in Switzerland and 
Italy. The B. cordatus, B. cristatus, and B. liguloides are very 
rare specimens. 

Symptoms. — Tape-worm is found in man at any period of his 



TAPE WORMS. 1267 

life. It may exist in man for an indefinite length of time and 
cause no disturbance whatever ; its presence certainly involves 
very little danger. Often, however, there is distress in the 
stomach and bowels, with nausea and, occasionally, diarrhoea, 
possibly accompanied with slight fever, headache, moderate 
thirst and coated tongue. It is in persons suffering from these 
attacks that spells of ravenous hunger occur most frequently. 
Nervous disturbances are rare, save in persons of an apprehen- 
sive disposition who are conscious of harboring tape-worm ; 
these soon become anxious, eagerly watch the slight deviation 
from perfect health, and suffer from symptoms of nervous irri- 
tability, even to chorea and convulsive action. In very rare 
cases convulsions and epilepsy have been observed. 

The Bothriocephalus may give rise to serious anaemia, with 
palpitation of the heart, dyspnoea, emaciation, great loss of 
strength and death. 

Diagnosis. — The diagnosis rests upon the evacuation of seg- 
ments with the stool or their escape from the bowels at other 
times. It is said that they pass away freely when the patient 
eats abundantly of fruit and of salted, pickled or spiced food. 

Treatment. — The prophylaxis consists of insuring that all 
meat used is thoroughly cooked, and in the proper care of any 
segments that may be passed. The latter should never be 
thrown away, upon the ground or into the water closet, but 
should always be burned. 

The treatment proper is necessarily heroic, and, to be success- 
ful, includes faithful attention to certain preparatory measures. 
First of all, the intestines must be thoroughly emptied by mild 
laxatives and the use of a copious enema of cool water. The 
patient must be kept on a light diet, preferably milk, for at 
least two days before the tape-worm remedy is given. German 
practitioners still favor the eating of a finely chopped salad 
made of salt-herring, with onions and garlic, for the purpose 
"of making the tape-worm ill," and the wisdom of the practice 
is borne out by the success which usually attends it. The 
bowels having been thoroughly emptied, the patient is allowed 
no food during the night and in the morning, and is given the 
medicine in the early part of the forenoon. Its administration 
is followed in two or three hours by a brisk purge. By this 
means the parasite is left without the protection of faecal mat- 
ter and its expulsion is rendered probable. 



12GS DISEASES DUE TO ANIMAL PARASITES. 

Of drugs, the following are the most reliable : Male fern, in 
the fresh ethereal extract, is given in one- or two-drachm doses, 
in form of an emulsion or in milk, still better in a capsule, with 
the usual preparatory treatment and purge after the last dose 
has been taken. Large doses of the extract or oleoresin ma}', 
however, cause intense gastro-intestinal irritation, and fatal 
results have followed the exhibition of two drachms of the 
oleoresin, given in three doses, in a child 5V2 years old. The 
bark of the Pomegranate root (Punica granatum) is a fav- 
orite taenicide. A decoction is made by macerating three 
ounces of the bark in twelve ounces of water, reducing the 
amount to one-half by evaporation, and giving a wineglassful 
every half hour until all has been taken. Its taste is exceed- 
ingly objectionable to some patients, but the medicine is ver\ r 
efficient. Its alkaloid, Pelletierine, a somewhat expensive sub- 
stance, may be prescribed instead, in doses of one-fourth to 
one-half grain, repeated two or three times, to be followed in 
due season by a brisk purgative. The Pelletierine tannate, 15 
grains at a dose, in capsules, is also very effective.— Kousso 
flower (Brayera) enjoys an extensive reputation. Struempell 
gives three or four powders, each containing seventy -five grains 
of the powdered flowers, in white wine, one glass of wine con- 
taining one powder, every half hour. The patient is directed 
to lie quiet to prevent vomiting. — Kamala, one to two 
drachms, mixed in molasses, has often answered the purpose. — 
Pumpkin seed (Pepo) deserves its long-established reputation, 
and has the advantage of being an easily obtained and inex- 
pensive remedy. Three or four ounces of the fresh seeds should 
be crushed or pounded in a mortar, then beaten into a paste 
with milk, and allowed to stand for several hours ; the result- 
ing emulsion is strained and may be sweetened with sugar to 
render it palatable. It is taken at one dose and followed Iry a 
brisk purge. 

The treatment cannot be considered effective unless the head 
of the tape-worm has been expelled ; the head remaining, the 
worm will rapidly grow again. In mam* cases repeated at- 
tempts must be made before success is insured. This applies 
particularly to the taenia solium. 

When a patient has passed through the ordeal of treatment 
for tape-worm, he should be kept quiet for some time and care 



CYSTICERCUS DISEASE. 1269 

exercised in the diet. The treatment should never be under- 
taken save upon ab'solute proof, by the expulsion of segments, 
that tape-worm is really present. 

CYSTICERCUS DISEASE. 

This results from the presence of the larvae of tape-worm in 
the-tissues of the body ; observation shows that with very rare 
exceptions the larvae are those of the pork tape-worm. In 
nearly every case the eggs are derived from the tape-worm of 
another host, though exceptionally ripe segments may enter 
the stomach of their host, as by violent vomiting, and the ova 
be set free, or, as may occur in the insane or in persons of un- 
usually filthy habits, the eggs may be transferred from the 
anus to the mouth, thus constituting a species of auto-infection. 
The egg swallowed, its shell is digested and the embryo set 
free ; the embryo enters the lymphatics or blood vessels and is 
carried to various parts of the body, where it eventually is 
transformed into a cyst of the size of a pea, or larger, contain- 
ing a clear fluid. In the course of about three months a head, 
with suckers and hooklets, is developed. A capsule may form 
around the larva by surrounding connective tissue ; if it have 
an abundance of room, as in the ventricles of the brain, it re- 
mains free. The cysticercus may live for many years and 
usually remains fixed ; or the larva may die and become calci- 
fied. It may occur isolated or the body may fairly swarm with 
them. They are found in the muscles, brain, heart, lungs, kid- 
neys, liver, eyes and bones. 

The symptoms depend very largely upon the organ which is 
occupied by the parasite. If the brain or cord, chronic menin- 
gitis or hydrocephalus may result. In the ventricles of the 
brain they attain considerable size from the absence of sur- 
rounding tissue the pressure of which might restrict their 
growth. In the eye they occur in the vitreous humor, causing 
disturbances of vision. When the muscles are invaded in large 
numbers, there is muscular stiffness and helplessness. Under 
the skin they form smooth, round, elastic tumors, not project- 
ing above the surface. Numbness and pain result in case of 
pressure upon peripheral nerves. Osier relates the case of a 
man who was admitted to his "wards stiff and helpless, so 



1270 DISEASES DUE TO ANIMAL PARASITES. 

much so that he had to be assisted up-stairs and into bed. He 
complained of numbness and tingling in the extremities and 
general weakness, so that at first he was thought to have a 
peripheral neuritis. At the examination, however, a number of 
painful subcutaneous nodules were discovered, which proved 
on excision to be cysticerci. Altogether seventy -five could be 
felt subcutaneousfy, and from the soreness and stiffness they 
probably existed in large numbers in the muscles." 

The diagnosis rests upon the recognition of the parasite in 
the eye or in a tumor removed from the skin or muscle. 

The treatment consists of their removal by surgical meas- 
ures. 

ECHINOCOCCIS DISEASE (HYDATID DISEASE). 

The taenia echinococcus is a small tape-worm, from 4 to 5 
millimetres long, in appearance like a white thread, with a 
small head which is provided with four suckers and a double 
row of hooklets, and composed of three or four joints, of which 
only the last is mature. It inhabits the intestine of the dog, 
fox, wolf and jackal; man becomes infected by ingestion of the 
eggs of the parasite into the stomach. The disease is common 
in countries where dogs abound and man is thrown into con- 
stant and close association with them ; hence its frequency in 
Australia and Iceland. In America it is rare, Osier's collection 
of cases from all sources in America and Canada consisting of 
a series of eighty-five. 

The egg having found entrance into the human stomach, its 
shell is digested and the embr3 r o set free. The embryo is carried 
by the blood current into some organ, usually by the portal 
vein to the liver, and there it fastens itself by means of its six 
little hooklets, to develop into a hydatid cyst, filled with a 
clear fluid ; this cyst is soon surrounded by a firm capsule of 
connective tissue. The cyst is composed of two layers: an 
outer cuticle of lamellated structure and an inner parenclryma- 
tous layer containing muscular fibres and blood vessels. In the 
course of four to six months the cyst attains the size of a wal- 
nut, and eventually that of a child's head. In the meantime 
buds develop from the inner layer, to grow into a second crop 
of cysts— "daughter cysts"— which in every way resemble the 



ECHINOCOCCUS DISEASE. 1271 

parent cysts to which they are at first united, but from which 
they soon separate, floating in the liquid contents of the parent 
cyst ; in the same manner another process of budding within 
the daughter cysts goes on, resulting in the formation of 
"granddaughter cysts." There are further generated from the 
parenchymatous layer of the parent and daughter cysts buds 
which develop into breeding capsules, from the lining mem- 
brane of which bodies gradually form which are known as 
scolices. The scolices are really heads of the parasites ; they 
possess the four sucking disks and the circle of hooklets ; each 
of these, transferred to the gut of a dog, fox or wolf, will be- 
come an adult taenia echinococcus. Thus each egg of this taenia 
is capable of developing into a cyst capable of producing an al- 
most untold number of larvae. 

It has been pointed out that in man the formation of daugh- 
ter- and granddaughter cysts proceeds from the inner mem- 
brane of the parent cyst, and this constitutes the endogenous 
form ; in animals the buds frequently penetrate through the 
layers of the parent cyst and the secondary and tertiary cysts 
are formed externally, i. e. the exogenous form. 

In still other instances the buds developing from the primary 
cyst are cut off entirely, encapsulated by connective tissue, 
joined together, and form in firm strands of connective tissue 
inclosing alveolar spaces about as large as a pea, in which are 
found the remnants of the cyst, sometimes containing scolices 
or hooklets. These constitute the multilocular echinococcus. 

The liquid within the cyst is clear, limpid, yellow, of neutral 
reaction, non-albuminous, with a specific gravity of 1.005 to 
1.015. It contains traces of sugar. 

The growth of the cyst is slow, and its life may cover many 
years, according to some authors even twenty years. Death of 
the cyst, often from inflammation of or injury to the capsule, 
is followed by corrugation and shrinkage of the walls, with 
inspissation and calcification of the cyst-contents ; or rupture 
may take place, possibly into a serous sac, or perforation 
through the skin, or into the bronchi, intestine, or urinary 
canal, even into the bile passages or inferior vena cava. The 
results of rupture vary ; the hydatids may be discharged ex- 
ternally, followed by recovery; or the termination may be sud- 
denly fatal. Suppuration and the formation of large abscesses 
is often seen in the liver. 



1272 DISEASES DUE TO ANIMAL PARASITES. 

Of 1862 cases, the parasites were found in the liver in 953, 
in the intestinal canal in 163, in the lung or pleura in 153, in 
the kidnej'S, bladder and genitals in 186, in the brain and spinal 
canal in 127, bone 61, heart and blood vessels 61, other organs 
158 (Neisser). 

Symptoms. — Hydatids of the Liver. — If the cyst be of moder- 
ate size, no symptoms may be experienced ; in fact, a post-mor- 
tem examination may reveal the presence of a dead calcified 
echinococcus cyst the existence of which was entirely unsus- 
pected during life. The cyst being large, there is likely to be a 
sense of pressure and of dragging in the region of the liver, 
sometimes considerable pain, usually of a dull character, and 
signs of tumor with enlargement of the liver. The latter will 
be indicated by bulging of the epigastrium or right hypochon- 
drium, with increase of the area of hepatic dulness according 
to the size and location of the cyst. Should the cyst be very 
large and situated on the convex surface of the liver, it is al- 
most sure to cause dyspnoea by crowding the diaphragm and 
compressing the lower lung. Compression of the portal vein 
or of large bile-duct is not uncommon, and results in ascites, 
splenic enlargement or jaundice. Pressure upon the hepatic 
vein or inferior vena cava causes oedema of the legs. Rupture 
of the cyst into the pleural cavity, lungs or intestinal canal 
may take place, resulting in inflammation ; if into the lungs, 
pneumonia, often complicated with abscess or gangrene, may 
follow, with expectoration of echinococcus vesicles. Rupture 
into the bile ducts gives rise to jaundice and the appearance of 
vesicles in the intestinal canal. Rupture into the hepatic vein 
and inferior vena cava has caused sudden death from em- 
bolism of the heart and of the pulmonary artery. In case of 
purulent inflammation, with hepatic abscess, the symptoms 
will be those of pyaemia, with chills, night-sweats, jaundice, 
emaciation and probably death. After the use of the aspirator, 
urticaria is frequent, probably due to the absorption of toxic 
matter from the cyst-contents. 

The multilocular cyst is almost limited to the liver. Such 
cases are always serious. The liver is enlarged and smooth, 
not uneven, to the touch. Jaundice, splenic enlargement, as- 
cites, great emaciation and loss of strength develop. The ter- 
mination usually is fatal. 



ECHINOCOCCUS DISEASE. 1273 

Diagnosis. — If the cyst can be felt on the surface of the liver, 
the diagnosis is easy. The tumor usually is firm and flat or 
round ; occasionally it is elastic. The so-called hydatid fremitus 
was at one time thought of great diagnostic value, but it has 
proved unreliable. It may be found in a superficial cyst by pal- 
pating lightly with the fingers of the left hand, at the same time 
percussing with those of the right. The sign consists of a vi- 
brating tremulous impulse or movement which persists for a 
time. The aspirator may be used to determine the character 
of the contents of the tumor. The actual demonstration of 
the presence of the echinococcus vesicle is, however, the only 
positive sign. 

The tumor of syphilitic disease of the liver is usually hard, 
not fluctuating. In cancer the constitutional symptoms are 
more severe and the cachexia pronounced, while in hydatids 
the general health remains excellent, even with great hepatic en- 
largement. In dilatation of the gall bladder the tumor is 
movable and its contents are mucoid. A pleural effusion on the 
right side may closely simulate an echinococcus cyst of the 
right lobe pushing up the pleura; in the cyst, the upper limit of 
the line of dulness presents a curved line the maximum of which 
is usually in the scapular region. 

Echinococcus of the Lungs and Pleura. — No symptoms are 
experienced while the vesicles in the lungs are small. When they 
are large, there is compression of the lung tissue, leading to in- 
flammation, possibly gangrene and cavity formation. Haem- 
optysis is not infrequent ; the expectoration contains the char- 
acteristic echinococcus vesicles. Perforation into the pleura is 
common, followed by sudden and severe pain, pleurisy, great 
dyspnoea and possibly empyema. Perforation of the pulmo- 
nary vessels leads to embolism and fatal haemorrhage. 

If the pleura is the seat of the affection, and the cyst is large, 
the symptoms are those of compression of the lungs, of hydro- 
thorax, and of displacement of the heart and diaphragm. The 
physical signs are those of pleural effusion, with very irregu- 
lar line of dulness. For a long time the general health may not 
suffer. The cysts may perforate the chest wall. Pleurisy is 
rare. 

Echinococcus of the Kidneys. — While about ten per cent, of 
Neisser's cases showed involvement of the urinary apparatus, 



1274 DISEASES DUE TO ANIMAL PARASITES. 

of Osier's series of 85 cases only three showed affection of the 
kidneys. The left kidney appears to be the seat of the parasite 
oftener than the right. The symptoms are those of a slowly 
progressing atrophy of the organ, with low inflammation and 
adhesions, and a totality of symptoms very closely resembling 
hydronephrosis, the entire kidney- becoming converted into one 
enormous cyst. General health remains undisturbed for a long 
time. Perforation oftenest takes place into the renal pelvis. 
The only positive means of diagnosis is puncture and examina- 
tion of the fluid. 

When the nervous system (brain) is the seat of the parasite, 
the symptoms usually are those of tumor, with stubborn head- 
ache, convulsions and gradually developing blindness. Thomas, 
of Australia, states that the cyst is oftener found in the cere- 
brum, and more frequently on the right than on the left side. 
In the peritonaeum, when invaded by the echinococcus, very 
large tumors are frequently formed, especially on the subperi- 
toneal tissues of the omentum and mesentery' ; they are also 
found on the pelvic walls, and vesicles may be free in the peri- 
toneal cavity. No distressing symptoms are felt until the cyst 
is large enough to cause d} r spnoea by crowding the diaphragm 
or until the stomach or intestines are compressed. Rupture 
may occur into the peritoneal cavity or, much more rarely, into 
the intestinal canal or vagina. The physical signs are those of 
the presence of fluid in the abdominal cavity. Puncture, per- 
formed with due care to guard against the escape of the con- 
tents of the cyst into a serous cavity, and examination of the 
fluid, affords the most reliable means of diagnosis. 

Treatment. — The treatment is purely surgical. Until recently 
the aspirator was used for the withdrawal of the fluid and pos- 
sible obliteration of the cyst. The extensive experience of Aus- 
tralian physicians has shown the futility of this method. They 
obtained much better results by boldly opening the cyst, thus 
securing complete evacuation. Suppuration sometimes fol- 
lows. If occurring in the liver, the treatment is that of abscess. 
Surgical interference is not justifiable unless the cyst is large 
and causes serious trouble. 

FLUKES. 

The trematodes or flukes are dangerous to man chiefly when 
present in large numbers. The following are the more impor- 



FLUKES. 1275 

tant : Distoma Hepaticum or liver flukes occupy the bile pass- 
ages and upper parts of the intestine, causing great enlarge- 
ment of the liver, with ascites and jaundice; in other cases a 
chronic cholangitis may be set up, with thickening and calcifi- 
cation of the walls of the bile ducts. 

Fluke-disease is endemic in Japan, and may exist for many 
years without serious results, but eventually diarrhoea, intes- 
tinal haemorrhage and ascites take place, with, usually, fatal 
termination. The diagnosis rests upon the presence of the eggs 
of the parasite in the dejections. The liver-fluke is described as 
" a flattened fluke of elliptical outline, about thirty millimetres 
in length, its greatest width being twelve millimetres ; it is pro- 
vided with two suckers." 

Distoma Haematobium or blood fluke (Bilharzia ha?matobia) 
is found chiefly in Egypt, also in Arabia and Southern Africa. 
It lives in the venous system, preferably in the portal vein and 
in the recto-vesical plexus of veins. It is presumed that the par- 
asite enters the system through the drinking water (water of 
the Nile) used by the natives, of whom, in Egypt, nearly one- 
half of the lower classes are said to be infected. The symptoms 
are intermittent haematuria, with more or less pain during mic- 
turition. This condition may persist for years without causing 
much trouble, and a cure may even result from the death of the 
parasite, usually when there is no further infection, as in the 
case of removal from the infected region. In some cases, bow- 
ever, the bleeding is very persistent from intense haemorrhagic 
inflammation of the urinary mucous membrane, anaemia be- 
comes profound, and there is great loss of strength and flesh; 
occasionally fatal results obtain. The diagnosis rests upon the 
recognition of the eggs of the parasite in the slimy urinary sed- 
iment ; they are easily recognized under the microscope with a 
low power, are ovoid in shape, translucent, so that the embryo 
is readily seen, and have a small spike at one end. 

Distoma Pulmonale or lung- or bronchial flukes are found in 
the bronchi of natives of China, Japan, Corea and Formosa, 
and probably gain access to the system by the drinking-water. 
Their presence causes cough and occasionally haemoptysis. The 
eggs may be found in the sputa. 



1276 DISEASES DUE TO ANIMAL PARASITES. 

ROUND WORMS. 

ASCARIASIS. 

Ascaris lumbricoides, round worm, occurs more often in man 
than any other parasite. It is found in all countries and at any 
time of life, but more frequently in small children. It is a round 
worm, in shape not unlike the earth worm, pointed at both 
ends, yellowish or faintly reddish in color, striated transversely, 
provided with four longitudinal bands, and in the female 
reaches a length of from seven to twelve inches, the male being 
three or four inches shorter. The eggs are brownish red, ellip- 
tical, have a thick covering, and measure six one-hundredths of 
a millimetre in length ; of these one female is said to produce 
about sixty millions. The eggs are found in the fasces and de- 
velop in moisture and warmth ; the maturing of the worm re- 
quires no intermediate host. It is probable that infection is 
oftenest brought about by means of drinking water or contami- 
nated food. The parasite lives in the small intestine, usually only 
one or two, but it may occur in larger, even enormous, numbers. 
If the latter, a palpable tumor may sometimes be felt and in- 
testinal obstruction result from the parasitical mass. Usualh' 
no S3 r mptoms are caused by the presence of the parasite ; but 
when a large number of the worms are present, there may be 
loss of appetite, nausea, distress in the bowels and irregular 
stool. In children of a nervous disposition, restlessness, fretful- 
ness, grinding of the teeth, and uneasy and fitful sleep at night 
are familiar S3'mptoms. The ascarides are in the habit of mi- 
grating to different parts, especially so when the patient is ill 
with some acute fever of which intestinal disturbances are a 
feature, or when he suffers from diarrhoea, d3 r sentery or cholera. 
The worm may get into the stomach, from which it is expelled 
by vomiting ; or it may crawl out of the anus and be found in 
bed; or it may get into the oesophagus and pharynx, and be 
thrown up or pulled out by the patient ; or it may enter the 
larynx, causing great distress of breathing, even fatal 
asphyxia ; or it may pass into the air tubes and give rise to 
fatal bronchitis ; or it may get into the gall bladder or bile 
duct, causing hepatic abscess ; or it may crawl into the Eusta- 
chian tube and appear at the external meatus. It may even 
perforate the intestine, causing peritonitis. 



ROUND WORMS. 1277 

Treatment. — Of the vermifuges, whose use is practically un- 
avoidable, santonine is by all means the most reliable. It 
should be given in capsule, gr. V± to V2 to a child two years old, 
three to five grains to an adult, to be followed by a brisk purge. 
Oil of chenopodium, two drops three times daily, for a day or 
two, followed by a dose of castor oil, and the old-fashioned 
mixture of the fluid extract of spigelia and of senna, have also 
a -well-deserved reputation. 

Oxyuris Vermicularis, the pin-worm or thread-worm, is a 
common intestinal parasite, and occurs in both adults and chil- 
dren, but much oftener in children. The male is about four mil- 
limetres in length, while the female measures from ten to twelve 
millimetres. It occupies the large intestines, chiefly the colon 
and rectum. The female provides an immense number of eggs, 
which are passed with the stool; they are small and, when dry, 
are blown about, and are then taken into the stomach with the 
drinking-water or in eating lettuce and other vegetables which 
-were indifferently cleaned ; in the stomach the action of the gas- 
tric juice sets free the embryo, and its development is so rapid 
that a young worm is produced within a fortnight. The eggs 
are frequently deposited about the anus, and self-infection un- 
doubtedly occurs often by transferring them to the finger-nails, 
in scratching, and from them to the mouth. The chief trouble 
arising from the presence of pin-worms is the local irritation 
and the intense itching produced by the movements of the par- 
asite, especially at night. Restlessness, uneasiness and in- 
ability to sleep are great in the majority of cases, and nervous 
children become almost frantic in their determination to re- 
lieve themselves by scratching ; in some cases the nervous irri- 
tability is intense and results in convulsions. The general 
health necessarily suffers ; the child loses its appetite, grows 
thin, and becomes anasmic. In little girls migration of pin- 
worm into the vagina is frequent, and may give rise to mas- 
turbation. 

The treatment consists of small doses of santonine, followed 
by a purge. When the child, at night, suffers excessively from 
itching, vaseline or belladonna ointment applied to the parts 
frequently affords much relief. It is, however, usually the bet- 
ter plan to fully awaken the child and administer a copious 
enema of cool water, made quite salty ; the hips should be 



1278 DISEASES DUE TO ANIMAL PARASITES. 

raised, to have the water retained for some time. Injection of 
carbolized water, also cool, answers the same purpose, wash- 
ing away the parasites and allaying the irritation of the parts. 
These injections should be repeated daily for a week or ten 
da3'S, santonine being exhibited in the meantime. Under this 
treatment, renewed as circumstances demand, permanent relief 
is finally obtained. Injections of vinegar, aloes, quassia and 
turpentine are recommended ; the latter should be used with 
some care. Certain remedies, although incapable of driving 
out the worm, are of value in controlling symptoms arising 
from their presence. Of these Cina is the most useful. It 
covers nearly the entire train of nervous symptoms which old 
nurses so readily recognize as due to "worms" and often af- 
fords surprisingly prompt relief. — Stanntjm is very useful 
when the nervous tension is not so great, but when there is 
much abdominal distress, marked gastric derangement, restless- 
ness, and the child lies on the abdomen, because the pressure 
thus obtained relieves the pain. Both Cina and Stannum 
often bring about the expulsion of large numbers of the para- 
sites.— Calcarea carbonica, Mercurius solubilis, Baryta 
carbonica, Kali muriaticum, Xatrum phosphoricum, Sul- 
phur and Lycopodium will be found helpful when symptomat- 
ically indicated. 

Ankylostoma Duodenale. — A white, thread-like worm ; the 
female fifteen, the male about ten millimetres, in length. The 
eggs are oval, about 52 micromillimetres long by 32 micromil- 
limetres broad, have a thin transparent shell and no opercu- 
lum. The larvae develop in moist earth and get into drinking 
water. When swallowed, the embryo escapes, and makes its 
home in the upper small intestine, chiefry the jejunum, causing 
the disease known as ankylostomiasis or dochmiasis. The 
parasite firmly fastens itself to the intestinal mucous mem- 
brane by its tooth-like hooklets. The harm done arises from 
the blood drawn by suction and from the irritation set up in 
the infected tissues. There is loss of appetite, nausea, vomiting, 
abdominal pain and intestinal catarrh, with serious disturb- 
ances of nutrition. The anaemia, however, depending some- 
what on the number of parasites in the body, in importance 
overshadows all other symptoms. It may progress rapidly 
from the beginning, presenting the usual train of symptoms 



ROUND WORMS. 1279 

which belong to that condition, or may assume the features 
belonging to the pernicious form, with fatal termination. Oc- 
casional^ there is dilatation and hypertrophy of the heart. 
Recovery may take place in case the parasite dies and there is 
no reinfection, but even then the patient is liable to be left in a 
condition of invalidism which may persist indefinitely. 

Bilharz, Griessinger and others have shown that the presence 
of this parasite is responsible for the severe forms of chlorosis 
found in Egypt, India and Brazil, possibly in the extreme 
southern part of the United States. The profound anaemia of 
laborers in tunnels, mines and brickyards is thought due to the 
same cause, the infection being conveyed in the drinking water. 

Treatment. — Prophylaxis consists in the exercise of great 
care in providing good drinking water ; it should be thoroughly 
boiled and properly stored. In some parts of Egypt, where the 
disease abounds, the inhabitants, it is said, are free earth- 
eaters, and thus swallow larvae. The removal of the parasite 
is brought about by the oleoresin of male fern in full doses, fol- 
lowed by a brisk purge, or by the exhibition of thymol, five 
grains every two hours until twenty grains are taken, f ollowed 
by a full dose of castor oil and turpentine. The diet should 
consist of milk and soup. 

Filaria Medinensis or Guinea worm is an elastic worm about 
two feet long, which is found chiefly in Guinea, Egypt and In- 
dia, and probably very rarely in this country; it is the cause of 
the disease known as dracontiasis. 

The female worm only has been observed. It contains a very 
large number of embryos which escape into the* water and de- 
velop in a small crustacean, man becoming infected by drink- 
ing the water. The female penetrates the intestine and finds a 
permanent habitat in the subcutaneous tissue, preferably in or 
about the feet, where it can usually be felt. Inflammation is 
eventually excited, followed by ulceration and suppuration ; the 
whole parasite may be discharged when the abscess breaks. 
Though usually solitary, six, or more, are known to have been 
present in the same person. 

Treatment consists in promoting suppuration and, in due 
time, winding the projecting end of the worm several times 
around a small bit of wood, then tightening it a trifle two or 
three times daily until the entire worm is withdrawn. Great 



1280 DISEASES DUE TO ANIMAL PARASITES. 

care must be had not to tear off a portion of the worm, lest 
the remainder will return to its habitat and not only keep up 
the inflammation, but still further infect the body by the mi- 
gration of embryos. 

Filaria Sanguinis Hominis. — Three species are here included : 
Filaria Bancrofti, F. diurna, F. perstans. Of these the former 
is the more important. The mature worm is hair-like and lives 
in the lymph-vessels, chiefly of the genito-urinary apparatus. 
The mosquito is thought to be its intermediate host. The em- 
bryo enters the blood through the lymphatics. It is encased in 
an almost invisible, elongated shell which does not appear to 
hinder its movements ; it is about the one-ninetieth part of an 
inch in length and in thickness of the diameter of a red blood 
corpuscle. They are remarkably active and more easily seen 
under the microscope, especially at that time of the twenty- 
four hours when the patient sleeps. No symptoms are pro- 
duced unless the worms or the ova block the lymph-channels ; 
then haematochyluria, elephantiasis and lymph-scrotum result. 

Haematochyluria consists of the passing, off and on, of milk} 7 - 
white or pinkish, bloody urine, which upon standing shows a 
slightly reddish clot and often a creamy layer on the top, due 
to the presence of fat-drops. The urine contains embryos of 
the filaria, which may also be seen in the blood of the patient, 
usually at night. The condition may exist for mam' years and 
not give the slightest trouble, but trifling vesical irritation and 
uneasiness in the lumbar region may be experienced. Blood- 
clots may collect in the bladder and cause inconvenience. In 
elephantiasis and lymph-scrotum there is inflammation of the 
wall of the lymphatics, obstruction to the flow of lymph, and 
dilatation and varicosis of the smaller lymph vessels. The fi- 
brous tissues of the scrotum are enormously thickened. Em- 
bryos are frequently found in the chylos fluid which escapes 
from the dilated superficial lymphatics. 

Haematochyluria, elephantiasis and lymph-scrotum ma}- all 
be non-parasitic. No method of treatment has proved effica- 
cious. 

Other round worms which very occasionally infest man are : 
Eustrongylus gigas, which has rarely been found in the urinary 
tract of man; the Strongylus longivaginatus (in the lungs of a 
child); Trichocephalus clispar, which lives in the caecum, but so 



TRICHINOSIS. — TRICHURIASIS. 1281 

far has not been shown to possess pathological importance ; 
Filaria Loa (in subjunctival tissue ; West Africa, South Amer- 
ica); Filaria lentis (present in cataract); Filaria bronchialis 
(bronchial glands), and Filaria lahialis (lip). 

TRICHINOSIS-TRICHINIASIS. 

This disease is caused by the embryo of the Trichina 
spinalis, which in the adult form lives in the small intes- 
tine. The female is three to four millimetres in length, the 
male from one to five, and is provided with two small projec- 
tiles from the hinder end. The larva is from six-tenth of one 
to one millimetre long, and lies coiled up in an ovoid capsule 
which is at first translucent, but becomes opaque and infil- 
trated with lime salts. When flesh containing trichinae is eaten, 
by man or by animals capable of developing them, the capsules 
are digested and the trichina? set free. They pass into the small 
intestine, there attaining their full growth, and usual maturity 
in about three days. The embryos, according to Virchow, are 
fully developed on the sixth or seventh day ; they at once leave 
the intestine, and, passing through the peritonaeum and connect- 
ive tissues, reach the muscles, making their home in the primi- 
tive muscle-fibres, and there develop into the full-grown muscle 
form in about two weeks. An interstitial myositis is inciden- 
tally excited, and an ovoid capsule forms around the parasite, 
and may contain three or four of them. The capsule thickens, 
and in the course of a few months lime salts are deposited 
within it, the parasite itself undergoing no further changes and 
living for an indefinite time, even twenty or twenty -five years, 
although often they are completely calcified. This process of 
calcification is very pronounced in man, and renders the cyst 
visible ; in swine calcification does not occur so constantly, and 
the cyst is not readily discovered. 

The trichinae thrive in many animals, but most abundantly in 
the hog. Swine may be fairly alive with them, and apparently 
not suffer in the least, but eat well and appear in excellent 
condition. 

Man is infected by eating the flesh of the trichinous hog, un- 
less the meat is thoroughly cooked, a process which destroys 
the parasites. Pickling and smoking the meat is not sufficient 
81 



1282 DISEASES DUE TO ANIMAL PARASITES. 

to accomplish this purpose. Trichiniasis, therefore, is most 
frequent in countries whose people eat raw or imperfectly 
cooked pork, as is done constantly in North Germany. Epi- 
demics of the disease, many persons having been infected from 
the same source, have occurred frequently, chiefly in North Ger- 
many, and occasionally in America, but on a less extensive scale 
in this country; Osier states that the Surgeon General's Li- 
brary shows the records of 456 cases in America. Post- 
mortem statistics prove that trichinae are found in V2 to 2 per 
cent, of all the bodies examined. 

Symptoms. — The intensity of the disease depends largely 
upon the extent of the infection ; if only a small number of 
trichinae are in the infected meat, the disturbance set up may be 
so slight as to pass unnoticed. 

Symptoms of gastro-intestinal catarrh usually occur a few 
days after eating the infected meat, with pressure in the epigas- 
trium, loss of appetite, vomiting, pain in the bowels, and diar- 
rhoea which may be choleraic in its intensity. In some cases 
there is very early a great deal of muscular pain and stiffness, 
which is not due to the migration of the parasites, accompa- 
nied with much debilit\\ The gastro-intestinal S3 r mptoms are 
not always observed, and in intensity differ much in different 
cases. 

The symptoms of invasion occur during the second week, 
usually from the seventh to the tenth day, sometimes later, and 
their violence depends largely upon the number of parasites in 
the body ; if the latter are few, the muscular sj-mptoms are 
slight. The condition set up by the migrating worms is a 
myositis, with great muscular pain with tenderness on pres- 
sure, aggravation from motion, and swelling and tension, in 
character resembling rheumatism, and compelling the patient 
to find a position in which the least possible tension is exerted 
upon the muscles ; he therefore lies with his limbs flexed and 
perfectly quiet. The patellar reflex is nearly always lost ; there 
is also a decided loss of muscular excitability to the electric cur- 
rent, according to Eisenlohr, sometimes -with delayed contrac- 
tions and abnormally long duration of the contraction after 
the stimulus ceases. Symptoms differ according to the loca- 
tion and functional importance of the invaded muscles. If the 
masseters and pharyngeal and laryngeal muscles are involved, 



TRICHINOSIS— TRICHINIASIS. 1283 

there is great difficulty in chewing and swallowing ; involve- 
ment of the motor muscles of the eye results in pain in the eye, 
which is often distressing ; invasion of the diaphragm, intercos- 
tal and abdominal muscles causes dyspnoea which is aggra- 
vated by the difficulty of clearing the air-passages from accu- 
mulated secretions, and may prove fatal. Fever, rarely chills, 
is nearly always present in the more serious cases, the tempera- 
ture reaching 102° to 104°, the fever itself partaking of an in- 
termitting or remitting character. CEdema accompanies the in- 
vasion of the muscles and constitutes an important symptom. 
It shows itself first, at the end of the first week, in the face, eye- 
lids, later in the extremities. Cutaneous eruptions, vesicles, 
wheals, petechia? and pustules are common. Profuse sweating, 
followed by crops of miliaria and sudamina, is very frequent, 
and adds to the similarity which trichiniasis bears to rheuma- 
tism. 

Emaciation usually progresses rapidly, and there is more or 
less anaemia. Consciousness in the majority of cases remains 
intact, but in the severest types delirium prevails, with dry 
tongue, rapid pulse and tremors, the totality of symptoms 
bearing a close resemblance to typhoid fever. In fact, as 
Struempell points out, the first case in which trichinosis was 
recognized at the autopsy, by Zenker, of Dresden, had been re- 
garded before death as typhoid. 

The urine usually is albuminous; in some epidemics pyluria is 
common. Bronchitis, pleurisy and pneumonia are complica- 
tions which frequently occur in fatal cases. 

Recovery takes place in two or three weeks, even sooner, in 
mild cases ; in the severer form, in from six to eight weeks, but 
it is tedious, and it may take many months before the muscles 
again acquire their normal vigor. In children the disease runs 
a milder course than in adults. The mortality ranges from 2 
to 33 per cent., and is greatest from the fourth to the sixth 
week. Death usually occurs from involvement of the respira- 
tory apparatus. 

Morbid Anatomy. — The changes in the muscles are character- 
istic. They are those of degeneration of the muscular fibres 
and, in the immediate neighborhood of the parasites, of acute 
interstitial myositis. The trichinae may be recognized in the 
muscles by the naked eye as little whitish lines. Fatty degener- 



1284 DISEASES DUE TO ANIMAL PARASITES. 

ation of the liver is comparatively frequent. The intestinal tract 
presents evidence of acute catarrh, with hemorrhagic effusions, 
and not infrequently, even in the fourth and fifth week of the 
illness, living trichinae are found in the intestines. It is on this 
account that a smart diarrhoea in the early stage of the disease 
is more liable to result in good, rather than harm, to the pa- 
tient. 

Diagnosis. — The most important diagnostic symptoms are 
the muscular pain, swelling, oedema and dyspnoea, especially if 
preceded by a choleraic condition. When such symptoms oc- 
cur in a number of people who have eaten pork, particularly 
about the same time, trichiniasis should be suspected and care- 
ful examination made of the meat eaten, of the stools of the 
sick, and of small bits of muscle taken from the patient under 
local anaesthesia. The trichinae are readily recognized in the 
stool by spreading it thinly upon a glass-plate or upon a dark 
background, a low-power lens showing trichinae as small glis- 
tening threads. Typhoid fever may closely resemble trichinia- 
sis, but it has its peculiar temperature curve, enlargement of 
the spleen, and lacks the muscular pain and rigidity belonging 
to trichinosis. Acute rheumatism has similar pain and profuse 
sweating; but in trichinous disease swelling of the joints is 
not conspicuous, if at all present, and there is characteristic 
gastro-intestinal irritation. Cholera may be distinguished by 
its intense muscular cramps and rice-water discharges. Acute 
antero-poliomyelitis lacks the acute gastro-intestinal symp- 
toms, is more steadily progressive, and runs a less rapid course. 

Poisoning by Ptomaines has the same violent gastro-intes- 
tinal irritation and, often, profound depression of the nervous 
system, but the characteristic muscular disturbances, oedema 
and dyspnoea of trichiniasis are not present. 

Treatment. — Under the head of prophylaxis must be placed, 
as of the greatest practical importance, all measures which 
tend to protect swine from trichinous infection. Here belongs 
due care in feeding the animals on clean, wholesome food, as 
grain, and not allowing them access to offal and filthy water. 
Systematic microscopic inspection of the flesh of all hogs killed 
is equally important. Unfortunately, nothing in this direction 
is done in the United States ; if insisted upon, it would not only 
protect the people against infection, but would amply repay by 



DISEASES DUE TO ARTHROPODES. 1285 

adding largely increased value to our export in pork. Further- 
more, thorough cooking of all pork consumed effectively de- 
stroys the parasites. Infection having occurred and having 
been discovered within a day, or two, complete evacuation of 
the intestine must at once be insured by the liberal use of full 
doses of rheubarb, senna, turpentine or other laxatives. Ger- 
man physicians are in the habit of using glycerine, a table- 
spoonful every hour. Furthermore male fern, santonine, 
thymol, and other drugs of the same class should be freely ex- 
hibited. If these measures fail, and the symptoms indicate the 
invasion of the muscles by the parasite, practically nothing can 
be done save to relieve pain, give rest at night, and support the 
strength of the patient. Struempell advises the use of the pro- 
longed hot bath. 

Symptom atically indicated remedies will aid in sustaining 
the patient and be of service in guiding him to a favorable ter- 
mination. 



DISEASES DUE TO ARTHROPODES. 

The acarus scabiei, sarcoptes hominis, or itch-insect. The fe- 
male appears to the naked eye as a barely visible, yellowish- 
white, hemispherical little body; under the microscope it proves 
to be crab-like, with a conical proboscis and eight legs. It is 
forty-five one-hundredths of a millimetre long and twenty-five 
one-hundredths of a millimetre in breadth. The male is smaller 
and lives on the skin and in shallow excavations of the epider- 
mis near the cuniculus which contains the female. It is said to 
die within six to eight days after impregnation of the female. 
The impregnated female alone bores a canal in the epidermis— 
the cuniculus— deposits from 20 to 50 eggs, and dies. The mite 
larva reaches its maturity in three to six days, breaks through 
the egg-shell, grows until it is 0.15 millimetres long and 0.10 
wide, and crawls to the mouth of the burrow. According to 
some writers it escapes through "air-holes" in the burrow, runs 
about the integument for a time, and finally bores its way into 
the nest, -where it passes through the moulting processes, 
moulting altogether three times. The parasites find their fav- 
orite locality upon the hands, especially where the skin is ten- 
der, i. e., between the fingers, and spread more or less rapidly 



1286 DISEASES DUE TO ANIMAL PARASITES. 

over the body. They are easily conveyed from one person to 
another, particularly so in those who are careless in their habits 
of cleanliness and in children. The migration of the parasites 
causes itching, especially at night, for which relief is sought by 
scratching, which results in excoriations and bleeding of the 
parts, with formation of crusts, particularly on sensitive parts, 
as the lower abdomen and the arm-pits, and often well-defined 
eruptions of a papular and ecthymatous character. 

The diagnosis depends upon the recognition of the burrows 
or cuniculi ; these, on exposed parts, are often destroyed bj r 
scratching; hence the wisdom of looking to parts less accessi- 
ble. The location of the irritation occurs in the following or- 
der of frequency and is important: flexor surface of the carpus, 
sides of fingers and folds between them, palm of the hands, ex- 
terior aspect of the elbow, anterior axillary fold, nipple and its 
vicinity in females, umbilicus and its vicinity, penis, scrotum, 
buttocks, inner border of the foot, and those parts which are 
subject to repeated pressure and whose epidermis is thickened 
(Kaposi). The discovery of the mite is conclusive. 

Treatment. — This consists of thoroughly washing the parts 
with a strong solution of soft soap, followed by careful wash- 
ing with pure warm water, and generous inunction with sul- 
phur ointment, which, in case of children, should be weakened. 

Naphthol ointment (one drachm to the ounce) is also efficient. 

While this treatment kills the itch-mite, and this is indispen- 
sable to a cure, it has no curative effect upon the skin-erup- 
tions which so often result, especially in scrofulous persons, 
from the long-continued irritation kept up b} r scratching the 
infected parts. Here lies the value of internal medications and 
the usefulness of remedies like Sulphur, Sepia, Psorinum, Mer- 
curius, Causticum, Arsenicum, Lycopodium, Natrum muriat- 
ICUM and others, according to their peculiar characteristic indi- 
cations. 

Others, which only require mention, are: Pentastoma dentic- 
ulatum, the larval form of P. taenioides, which reaches the nos- 
trils, liver, spleen, kidneys, heart, and lungs, and there becomes 
encapsulated. In two months it perforates the cyst walls, and 
is set free. No serious results are attributed to it. Pentastoma 
constrictum is common in Egypt, but has rarely been found in 
America; it has been ejected from the mouth and with the 



PARASITIC INSECTS. 1287 

urine. The Demodex folliculorum lives in the sebaceous folli- 
cles, especially of the skin of the face, but has no pathogenic 
importance. The Itodes ricinus and I. Americanus are " ticks " 
which occasionally fasten themselves upon the skin, causing 
itching and slight local irritation. In their removal care must 
be exercised not to tear off the head; should this accident occur, 
the head must be picked out with the point of a knife or a 
needle. The Leptus irritans (harvest mite) also attaches itself 
in large numbers to the skin, causing itching and local papular 
or pustular inflammation. 

PARASITIC INSECTS. 

Pediculus or Louse. — Three varieties infest man: P. cap- 
itis, P. vestimentorum, P. pubis. Both the head and 
the pubic louse lay their eggs among the hairs, the former 
of the scalp, the latter of the symphysis pubis ; in either 
case the eggs are firmly glued to the hair, appearing as 
minute whitish specks (nits). Great itching results, followed 
by scratching. In the case of infection of the head, there 
is a copious exudation of serous bloody fluid, which soon 
stiffens, matting the hair together, and sometimes form- 
ing a tangled and exceedingly filthy mat (plica Polonica of the 
Polish Jews). The pubic louse, the smallest of the three varie- 
ties, caiises similar irritation and frightful itching, but one of 
the chief annoyances arising from infection with it lies in the 
frequent conveyance of the mite to other hairy parts, as the 
arm-pit, beard, eye-brows and eye-lashes. The Pediculus ves- 
timentorum lives in the clothing, chiefly in articles worn next to 
the skin, but causes irritation by the bites which it inflicts, 
preferably between the shoulder blades, around the waist and 
upon the buttocks, leading to scratching, excoriations, forma- 
tion of crusts, ulceration, etc. The tough, pigmented and 
scarred condition of the skin which results from the perpetual 
presence of these insects is known as "Vagabond's Disease." 

Treatment.— The treatment is simple and efficacious. If the 
head is infected it is absolutely necessary to cut the hair short, 
else the nits cannot be destroyed. If the hair thus cut short is 
saturated with coal-oil, turpentine, or a lotion of carbolic 
acid (1:50), it will usually put an end to the trouble. Sulphur 



1288 DISEASES DUE TO ANIMAL PARASITES. 

ointment may be used, but sparingly. Mercurial ointment 
should be avoided here, lest it give rise to systemic mercurial 
poisoning. In case of the pubic louse, the parts had better be 
shaved or the hair cut as close as possible. Mercurial ointment 
should then be applied, and the parts thoroughly washed two 
or three times daily with soft soap and water. In the case of 
bod3^-lice, the clothing must be thoroughly disinfected by being 
kept for several hours subjected to great heat, and if necessary 
and possible, it should be burned. A hot bath, to which from 
•/4 to % pound of common washing-soda has been added, 
should then be given to the infected person, great care being 
taken in each case to prevent reinfection by observing rules of 
the strictest personal cleanliness and by avoiding association 
with suspected persons. 

Wood recommends the following lotion as very soothing: one 
ounce of alcohol ; one ounce of glycerine ; two drachms of car- 
bolic acid; fourteen ounces of water. Mix. 

Citnex Lectularius (Common Bed-hug). — This parasite lives in 
the joints of wooden bedsteads and in the cracks of the walls 
and floors of buildings. It is of reddish brown color, about 
four millimetres long, and has a peculiar, offensive odor. Its 
habits are nocturnal ; by means of a long proboscis it sucks the 
blood of man during his sleep. In some persons it thus causes 
a violent urticaria. The parasite may be destroyed by thor- 
ough fumigation with sulphur or by scouring with kerosene or 
a 10 per cent, solution of corrosive sublimate. Alkaline baths 
and a lotion of carbolic acid relieve the irritation of the skin. 

Pulex Irritans, or flea, lyy its sting causes a minute haemor- 
rhage and, in some persons, a violent diffuse erythema or urti- 
caria. The free use of insect powder will usually help keep 
away the flea ; it is said on the Pacific coast that the oil of 
eucalyptus, freely used on the body and about the bed, often 
answers the same purpose. The results of a "flea-bite" upon 
those who are liable to suffer from it may be ameliorated by 
rubbing the stung part with dry salt, or bathing it with a 
strong solution of washing-soda, or anointing it with the oil of 
eucalyptus. In some instances all measures of relief fail. 

Pulex Penetrans (sand-flea, jiggers) lives in the tropics. It 
penetrates the skin, preferably between the toes and under the 
toe-nail, causing inflammation, swelling, ulceration and occa- 



PARASITIC INSECTS. 1289 

sionally the loss of the toe. The use of strong aromatic oils on 
the feet is said to protect. It is removed by the point of a 
knife or a needle. 

Myasis. — The term Myasis is used to express the result of the 
presence of maggots in different parts of the body of man, due 
to the invasion by flies of inflamed or eroded mucous membrane 
or of open wounds in any part of the body. Any of the flies 
(common housefly, horse-fly, bot-fly, etc.) may be attracted 
to these diseased structures and deposit their eggs upon them, 
from which the larvae are developed in due time. This is espe- 
cially common in the tropics. As a result of such invasion the 
existing lesion is much intensified ; inflammation is greatly in- 
creased, destruction of tissue progresses rapidly, and severe 
constitutional symptoms may be provoked. 

The treatment lies in the removal of the larvae. If found in 
an open wound, they may be picked off; if in a sinus, they must 
be destroyed by injection. Absolute cleanliness and thorough 
antisepsis are all-important. 

Internal myasis may result from swallowing the larvae of the 
common house-fly or of species of the genus Anthomya. 

Bot-flies are known to have penetrated the skin of man, and 
deposit their eggs, from which larvae develop, causing boils and 
abscesses with, often, severe constitutional symptoms. Occa- 
sionally the eggs are swallowed and marked gastric and intesti- 
nal irritation produced by the larvae. In the latter case relief 
is given by free purging with a mixture composed of one part of 
oil of turpentine and three parts of castor oil. Such cases are 
common in Central America, Africa and Russia, but are infre- 
quent in the United States. 



INDEX. 



Abdominal aorta, aneurism of, 1143. 

Abdominal typhus, 19. 

Abscess, of appendicitis, 843, 846; of 
atheroma, 1128, 1129; of brain, 554; 
of cystitis, 1252; extra-peritoneal, 
842; of glanders, 308; of heart- 
muscle, 1 100; of kidney, 1248; 
of liver, 885; of lungs, 1019; of 
malignant endocarditis, 1061; of 
mediastinum, 1042; of parotid 
glands, 154; of tonsil, 731; peri- 
nephric, 1248; peritonsillar, 721; 
p3^aemic, 184; retropharyngeal, of 
tropical liver disease, 886. 

Abscess, extraperitoneal, of right 
fossa, see appendicitis, 842. 

Abscess of lung, 1019; diff. diagn. fr. 
pulmonary tuberculosis, 240; in 
aspiration and deglutition pneu- 
monia, 1019; pyaemia as a cause 
of, 1020. 

Abscess, peritonsillar, see phlegmo- 
nous laryngitis, 721. 

Abscess, retro-pharyngeal, diff. diagn. 
fr. pseudo-membranous laryngitis, 
971. 

Acarus scabici, 1285. 

Accessory spasm, 635. 

Acetic acid test for albumin, 1198. 

Acetonsemia, 362. 

Acetonuria, 1205. 

Achilles tendon reflex, 568. 

Acromegaly, 645; diff. diagn. fr. oste- 
itis deformans of Paget, 646; facial 
enlargment in, 646; symptoms, 
645. 

Actinomycosis, or ray-fungus, 310. 

Actinomycosis, 310; in alimentary 
canal, 310; in brain, 311; in lungs, 
311; in skin, 311; diff. diagn. fr. 



pyaemia, 311; fr. tubercu 

losis, 311; treatment, 311. 

Acute bulbar paralysis, 609. 

Acute amygdalitis, see acute tonsilli- 
tis, 729. 

Acute ascending paralysis, 584. 

Acute delirium, see acute perienceph- 
alitis, 398. 

Acute hydrocephalus, see tubercular 
meningitis, 522. 

Acute pneumonic phthisis, 225. 

Acute polymyositis, 651. 

Acute polio-myelitis of adults, 580. 

Acute rickets in children, 383; diff. 
diagn. fr. scurvy, 383. 

Addison's disease, 11 73; asthenia 
in, 1 1 74; diagnosis, 11 75; ex- 
tract of supra-renal glands of 
animals in treatment of, n 75; 
pigmentation of skin in, 1174; 
supra-renal glands, relation to, 

1173- 

Adenis, 1 169. 

Adenoid growths in chronic tonsilli- 
tis, 736. 

Adherent pericardium, see chronic ad- 
hesive pericarditis, 1055. 

Adiposure, 1202: 

Adrenals in Addison's disease, 1173. 

Aglyphia, 548. 

Agraphia, 548. 

Ague, see malaria fever, 58. 

" Ague-cake," 76. 

Agensia, 633. 

Ainhum, 648. 

" Air-hunger " in pneumothorax, 
1038. 

Albumin, tests for, 1198. 

Albuminuria in acute Bright's disease, 
1 214; chronic interstitial nephritis, 



1292 



INDEX. 



1227; chronic parenchymatous 
nephritis, 1222; cyclic — , 1197; 
diabetes, 361; diphtheria, 87; 
erysipelas, 178; functional, 1197; 
life insurance, 11 97; pneumonia, 
1003; pregnane}-, 11 97, 12 15; re- 
nal, U9S; rheumatic fever, 326; 
scarlet fever, 102, 105. 

Albuminuric retinitis, 1228. 

Alcaptonuria, 1206. 

Alcoholic coma, diff. diagn. fr. cere- 
bral haemorrhage, 537. 

Alcoholic insanity, 662. 

Alcoholic neuritis, 614. 

Alcoholism, 661; acute form, resem- 
blance to cerebral apoplexy, 537, 
661; apomorphia in treatment of, 
665; cause of tissue-changes in, 
661; cirrhosis of liver in, 663; de- 
lirium tremens, 663, 666; digestive 
disturbances in, 661; nervous 
symptoms of, 662; pneumonia a 
complication of, 665 ; renal disease 
in, 663, treatment of, 665. 

Alcoholism in relation to fibrous hepa- 
titis, 891. 

Alexia, 548. 

Algid form of pernicious malarial 
fever, 72. 

Allantiasis, 676. 

Allocheiria, 591. 

Alopecia of leprosy, 305; of syphilis, 

273- 
Alternate (or crossed) hemiplegia, 535. 
Altitude in consumption, 245. 
Amaurosis, hysterical, 441; toxic, 621, 

622; uraemic, 1209. 
Ambulatory form of typhoid fever, 23. 
Amimia, 548. 
Ammoniacal decomposition of urine, 

1204. 
Ammoniaemia, 1235. 
Amnesia, 547. 

Amoeba coli, 1263; a. dysenterica, 1263. 
Amoebae coli in dysentery, 200. 
Amoeboid dysentery, 201. 
Amputation neuroma, 618. 
Amuria, 548. 



Amyloid disease of kidney, 1231; of 
liver, 897; of syphilis, 275. 

Amyotrophic lateral sclerosis, see pro- 
gressive spinal muscular atrophy, 
606. 

Amyotrophic lateral sclerosis of Char- 
cot, 608. 

Anaemia from Bilharzia, 1275; from 
bothriocephalus, 1267; in anchy- 
lostomiasis, 1278; in chlorosis, 
1 157; in gastric cancer, 798; in 
gastric ulcer, 784; Hodgkin's dis- 
ease, 1 171; idiopathic, 1161; from 
lead-poisoning, 669; in malarial 
fever, 60, 76; primary or essential, 
1 154; progressive pernicious, 1161; 
secondary- or symptomatic, 1153. 

Anaemia, secondary, 1 153; anaemic 
murmurs in, 11 54; pulmonary 
oedema in, 1154; valvular insuffi- 
ciency in, 1 154. 

Anarthria, 546. 

Anasarca, see dropsy. 

Anchylosis, spurious, in rheumatic ar- 
thritis, 343. 

Anchylostoma duoden, 1278. 

Aneurism, 1132; contents of, 1133; 
diffuse, 1 133; dissecting, 1133; va- 
rieties, 1 133. 

Aneurism of abdominal aorta, 1143; of 
coronary arteries, 1143; of pul- 
monary artery, 1142; of thoracic 
aorta, 1134. 

Aneurism, diff. diagn. fr. morbid 
mediastinal growths, 1042. 

Angina Ludovici, 728. 

Angina maligna, see diphtheria, 81. 

Angina of scarlatina, diff. diagn. fr. 
acute tonsillitis, 732. 

Angina pectoris, 1120; arterio-sclerosis 
in, 1 122; diff. diagn. fr. cardiac 
asthma, n 22; diff. diagn. fr. car- 
diac crises of locomotor ataxia, 395 ; 

fr. hysterical angina, 1122; 

fr. pseudo-angina, 1122; elec- 
tricity in, 1 124; paroxysms of, 1121; 
vasomotor form of, 1122. 

Angina simplex, 705. 



INDEX. 



1293 



Angina tonsillaris, see acute tonsil- 
litis, 729. 

Angioma of liver, 900. 

Angio-neurotic oedema, 644; gastro- 
intestinal crises in, 644. 

Anisocoria, 623. 

Ankle-clonus, 568. 

Ankylostomiasis, 1278. 

Anorexia nervosa a symptom of hys- 
teria, 443. 

Anosmia, 619. 

Anthracosis, 1010. 

Anthrax, 186; bacillus anthracis, 186; 
forms of, 187; treatment, 188. 

Antipneumotoxin, 999. 

Antitoxin of diphtheria, 99; of tetanus, 
300. 

Anuria, 1193. 

Aorta, rupture of, 1145. 

Aorta, stenosis of, 1144. 

Aortic aneurism, 11 34. 

Aortic insufficiency, 1072. 

Aortic stenosis, 1076. 

Aphasia, 546; ataxic, 548; causation 
of, 549; mind-blindness, 547; mind- 
deafness, 548; sensory — , 546, 
Starr's description of. 546; tests 
for, 548; treatment, 549; word- 
blindness, 547; word-deafness, 
54«. 

Aphemia, see aphasia, 546. 

Aphthous sore throat, see herpetic 
pharyngitis, 717. 

Aphthous stomatitis, diff. diagn. fr. 

ulcerative — , 696; fr. thrush, 

694. 

Apoplectic habit, 530. 

Apoplexy, cerebral, 530; ingravescant, 
533; pulmonary, 995. 

Apoplexy, diff. diagn. fr. acute alco- 
holism, 661. 

Appendicitis, 842; abscess in, 843, 846; 
diagnosis, 847; diff. diagn. fr. in- 
testinal obstruction, 859; fr. 

renal colic, 1242; fr. strang- 
ulation and intussusception, 847; 
fever in, 844; forms of, 842 [acute 
infective, 843; catarrhal, 842; 



chronic, 843; obliterative, 843; 
perforative, 843; ulcerative, 843]; 
pain in, 844; peritonitis in, 844, 
846; surgical interference in, 848; 
treatment, 847. 

Appendicular colic, 845. 

Apraxia, 546. 

Aprosexia, see chronic tonsillitis, 734. 

Arachsistis, see meningitis, 517. 

Aran-Duchenne type of progressive 
muscular atrophy, see progressive 
spinal muscular atrophy, 606. 

Ardent continued fever, a form of 
heat-exhaustion, 682. 

Arsenical intoxication, 674. 

Arcus senilis, 1106. 

Argyll-Robertson pupil, 623; in 
ataxia, 592. 

Arithmomania, 397. 

Arteries, diseases of, 1126. 

Arterio-capillary fibrosis, see arterio- 
sclerosis, 1 1 26. 

Arterio-sclerosis, 11 26; aneurismal di- 
latation in, 1 1 29; diffuse changes 
in, 1 1 28; in coronary arteries, 
1 1 30; cerebral symptoms of , 11 30; 
in aortic insufficiency, 1073; local- 
ized changes in, 1128; pulse in, 
1129; renal disease in, 1127, 1130; 
senile form of, 1128. 

Arterio-venous aneurism, 1133. 

Arteritis, acute, 11 26. 

Arteritis deformans, see arterio-sclero- 
sis, 1 126. 

Arteritis, syphilitic, 282; tuberculous, 
268. 

Arthralgia from lead-poisoning, 670. 

Arthritis deformans, see rheumatic 
arthritis, 340; diff. diagn. fr. gout, 
352. 

Arthritis, local, of shoulder-joint, 344. 

Arthritis of infants, diff. diagn. fr. 
rheumatic fever, 329. 

Arthritis, septic, diff. diagn. fr. rheu- 
matic fever, 329. 

Arthropathies of tabes, 594. 

Arthropodes, diseases due to, 1285. 



1294 



INDEX. 



Articular rheumatism, diff. diagn. fr. 
gout, 351. 

Asiatic cholera, 189; comma bacillus 
of Koch in, 189; complications, 
193, 194; contagiousness of, 19] ; 
contaminated water a medium of 
infection, 190; cramps in, 192; 
diarrhoea of, 192; diff. diagn. fr. 
pernicious malarial fever, 74; mor- 
tality in, 194; Pettenkofer 's sub- 
soil theory in, 190; prophylaxis, 
195; stages of, 191; temperature in 
collapse, 192; treatment, 194; 
types of, 193. 

Ascariasis, 1276. 

Ascaris lumbricoides, 1276. 

Ascites, 938; diff. diagn. fr. distended 
bladder, 940; — — fr. chronic 

peritonitis, 934; fr. ovarian 

cyst, 940; pilocarpine in, 941; 
tapping in, 940. 

Ascites from acute peritonitis, 926, 927; 
from cirrhosis of liver, 893; from 
morbid growths and syphilis of 
liver, 901; from tubercular peri- 
tonitis, 934. 

Aspiration in acute pleurisy, 1029. 

Aspiration pneumonia, ion, 1019, I 
1020. 

Ascenic form of pernicious malarial I 
fever, 72. 

Asthma, bronchial, 989; humid, 983; 
in aortic aneurism, 1136; thymic, 
see laryngismus studulus, 967. 

Ataxia, hereditary, 599. 

Ataxic gait, 592. 

Ataxic paraplegia (Gowers'), 588. 

Atelectasis, pulmonary, 1012. 

Atheroma, see arterio-sclerosis, 1126. 

Athetosis, 551. 

Athlete's heart, 1073. 

Atonic dyspepsia, 769; diff. diagn. 
from gastric catarrh, 764. 

Atrophic spinal paralysis, see myelitis 
of anterior horns, 577. 

Atrophy of brain, 401, 550; of liver, 
883; of muscles, 652; progressive 



muscular, of spinal origin, 577' 

unilateral, of face, 648. 
Atrophy, spinal muscular, 606, 
Auditor}- nerve, diseases of, 630; dys- 

acusis, 630; hyperacusis, 630; 

tinitus aurium, 630. 
Auditory vertigo, 631. 
Aura in epilepsy, 453, 455. 
Auricular hypertrophy of the heart, 

1093. 

Bacillus anthracis, 186; b. diphtheriac, 
81; b. of Klebs-Lceffler, 83; b. 
leprae, 303; b. mallei, in glanders, 
306; b. pneumoniae, 999; b. pro- 
teus fluorescens (Jceger), 315; b. 
tuberculosis, 213 ; Ehrlich's 
method of staining, 211; Heneage 
Gibbs's method of staining, 232. 

Balanitis in diabetes, 362. 

Balantidium coli, 1264. 

Banting's treatment of obesity, 686. 

Barlow's disease, 383. 

Barrel-shaped chest in emphysema, 
1017; in enlarged tonsils, 738. 

Basedow's disease, see exophthalmic 
goitre, 1 1 79. 

Basilar meningitis, see tubercular 
meningitis, 522. 

Beast-mimicry, a symptom of hysteria, 

443- 

Bed-bug, 1288. 

Bed-sores, Balsam of Peru in, 33. 

Bell's (Luther) disease, see acute peri- 
encephalitis, 398. 

Bell's palsy, 627. 

Beri-beri, 615. 

Bile coloring matter, tests for, 905. 

Bilhargia haematobia, 1275. 

Biliary colics, 909. 

Bilious form of pernicious malarial 
fever, 72. 

" Bilious-typhoid," a form of relapsing 
fever, 47. 

Birth palsies, 551, 587. 

Black small-pox, 132. 

"Black vomit," see yellow fever, 49. 

Black vomit in yellow fever, 52. 



INDEX. 



1295 



Bladder, diseases of, 1250. 

" Bleeders," 385. 

Blepharospasm, 629. 

Blood-poisoning in farcy, 308. 

Blood-serum therapy in diphtheria, 99; 
in tetanus, 300. 

Blood-vessels, diseases of, 1126. 

' ' Blue line ' ' on gums in lead-poison- 
ing, 669. 

Bodily surface, pallor of, in progres- 
sive pernicious ansemia, 1161. 

Bone lesions in acromegaly, 645; in 
rickets, 374. 

Bone-marrow treatment of progressive 
pernicious ansemia, 11 64. 

Borborygmi in diarrhoea, 813. 

Bothriocephalus, 1266. 

Botulism, 676. 

Brachial plexus, diseases of, 639. 

Bradycardia, 11 19. 

Brain, abscess of, 554; anaemia of, 528; 
aneurism of, 544; cysts of, 557; 
echinococcus of, 1274; glioma of, 
556; hyperemia of, 529; oedema 
of, 529; softening of, 541; syphilis 
of, 279, 556; thrombosis and em- 
bolism of, 545; tubercle of, 556; 
tumors of, 556. 

Brain, abscess of , diff. diagn. fr. tumor 
of brain, 560. 

Brand's method of using the bath in 
typhoid fever, 33. 

Break-bone fever, see dengue fever, 

79- 

Brighfs disease, acute, I2n; diet in, 
1217; dropsy in, 1214; hot baths 
in, 1217; interstitial renal tissues, 
changes in, 12 13; prognosis, 12 16; 
renal epithelium, changes in, 1212; 
uraemia in, 1214; urine in, 1213. 

Bright 1 s disease, chronic, 1220. 

Brighfs disease, second stage of, 1220. 

Brighfs disease, third stage of, 1225. 

Broken compensation in mitral insuffi- 
ciency, 1067. 

Broken compensation in valvular dis- 
ease of the heart, 1086. 

Bronchial asthma, 989. 



Bronchial catarrh, see bronchitis, 976. 

Bronchial blennorrhoea, 982. 

Bronchiectasis, 988; a cause of pul- 
monary gangrene, 1020; diff. 
diagn. fr. pulmonary tuberculosis, 
240; in chronic bronchitis, 981; in 
bronchorrhcea, 983; in chronic in- 
terstitial pneumonia, 1009. 

Bronchiolitis, 990. 

Bronchitis, acute, 976; complicating 
other diseases, 976, 1002, 1018; 
cough in, 977; in the aged, 977; 
in the young, 977; Turkish bath 
in, 978. 

Bronchitis, capillary, see broncho- 
pneumonia, 1010. 

Bronchitis, chronic, 981; climate in, 
983; diff. diagn. from pulmonary 
tuberculosis, 239; forms of, 982; 
inhalation-treatment of, 984. 

Bronchitis, croupous, see fibrinous — , 
986. 

Bronchitis, fibrinous, 986. 

Bronchitis, fetid, 983. 

Bronchitis of old men, 982. 

Bronchitis, plastic, see fibrinous — ,986. 

Bronchitis, pseudo-membranous, see 
fibrinous — , 986. 

Bronchocele, see goitre, 1176. 

Broncho-pneumonia, ioro; age a factor 
in, ion; aspiration pneumonia a 
form of , ion, 1014, 1015; cerebral 
symptoms in, 1013, 1015; cod-liver 
oil in, 2015; complicating diph- 
theria, 87; complicating measles, 
122; deglutition pneumonia, a 
form of, ion, 1014, 1015; diagno- 
sis, 1014; diff. diagn. from lobar 
pneumonia, 1014; dyspnoea in, 1013; 
emetics in, 1015; essential lesions 
of, 1012; fever of, 1012; in infants, 
1013, 1015; sequel of typhus fever, 
43; tartar emetic in, 1016; treat- 
ment of, foi5; tubercular infec- 
tion in, ion. 

Broncho-pneumonia, acute tubercu- 
lous, 227. 

Bronchorrhcea, 982. 



1296 



Bronze skin in Addison's disease, 1174; 

in Basedow's disease; in Hodg- 

kin's disease, 1171. 
Brown atrophy of the heart, 1099, 1105. 
Brown induration of lungs in mitral 

insufficiency, 1067. 
" Bruit de diable " in chlorosis, 1157. 
Bulbar paralysis, 609; apoplectiform 

type, 609; chronic — , 609; treat- 
ment, 611. 
Bulimia, 361. 
Burns of the skin a canse of catarrhal 

enteritis, 812; of acute nephritis, 

1212. 



Caisson disease, 489. 

Calcareous concretions in phthisis, 
215; in tonsils, 737. 

Calcification of arteries, 11 29. 

Calculi-biliary, 909; coral, 1239; pan- 
creatic, 923; renal, 1239; tonsillar, 

737- 

Calculi, renal, of carbonate of lime, 
1240; of cystine, 1240; of indigo, 
1240; of oxalate of lime, 1240; 
phosphatic, 1240; uric acid, 1240; 
urostealiths, 1240; xanthine, 1240. 

Calculous pyelitis, 1233. 

California, southern, climate in tuber- 
culosis, 248; chronic bronchitis, 
983; bronchial asthma, 991; in 
chronic nephritis, 1230. 

Camp-fever, see typhus fever, 40. 

Cancer of the: brain, 556; gall-bladder, 
914; gall-ducts, 914; kidney, 1245; 
intestine, 875; liver, 899; lung, 
1022; peritonaeum, 937; pleura 
and lungs, 1022; stomach, 794. 

Cancer, pulmonary, diff. diagn. fr. 
pvilmonary tuberculosis, 240. 

Cancer of stomach, diff. diagn. fr. 
gastric catarrh, 764. 

Cancerous ulceration of pharynx, 716. 

Canker in the mouth, 692. 

Canned meats, poisoning by, 676. 

Capillar}' bronchitis a complication of 
diphtheria, 87. 



Capillary bronchitis in epidemic in- 
fluenza, 145, 146. 

Caput medusae, 939. 

Caput quadratum a sign of rickets, 
375- 

Carbolic acid for disinfecting cholera- 
stools, 196. 

Carbuncle in diabetes, 362. 

Cardiac asthma in valvular disease, 
1080. 

Cardiac murmurs in: aortic insuffi- 
ciency, 1075; aortic stenosis, 1077; 
chlorosis, 1157; chorea, 476; 
mitral insufficiency, 1069, 1072; 
mitral stenosis, 1072; tricuspid 
valve disease, 1078. 

Cardiac stimulants in pernicious ma- 
larial fever, 74. 

Cardialgia, see gastralgia, 767. 

Carpo-pedal spasms resembling tetany, 
483. 

Casts in urine, 1207. 

Catalepsy a form of hysteria, 439. 

Cataract in diabetes, 362. 

Catarrh, acute gastric, 754; acute 
nasal, 945; autumnal, 952; bron- 
chial, 976; chronic gastric, 947; 
chronic nasal, 761; dry, 982; in- 
testinal, 810. 

Catarrh, autumnal, see hay fever, 952. 

Catarrh, dry, a form of chronic bron- 
chitis, 982. 

Catarrhal tendency an expression of 
lithaemia, 351. 

Catarrhe pituiteux of Ltznnec, 983. 

Catarrhesec of Lcennec, 982. 

Cauda equina and conus medullaris, 
lesions of, 605. 

Cavities, pulmonary, signs of, 229. 

Cephalalgia, see headache. 

Cephalodynia, 336. 

Cercomonas hominis, 1264. 

Cerebellar heredo-ataxia {Marie), 
600. 

Cerebral anaemia, 528; in chronic my- 
ocarditis, 1 1 03. 

Cerebral aneurism, 544. 

Cerebral apoplexy, 530. 



1297 



Cerebral complications in rheumatic 
fever, 327. 

Cerebral embolism and thrombosis, 
541; symptoms of occlusion of: 
anterior cerebral artery, 543; 
basilar artery, 543; carotid artery, 
543; middle cerebral artery, 543; 
mitral stenosis, 1085; posterior 
cerebral artery, 544; vertebral 
artery, 543. 

Cerebral haemorrhage, 530; arterio- 
sclerosis a factor in, 530; conscious- 
ness, recovery of, 534; contract- 
ures, 536; diagnosis, 537; diff. 
diagn. fr. alcoholic coma, 537; — 

— fr. coma of epilepsy, 538; 

fr. coma of opium-poisoning, 538; 
fr. ursemic coma, 538; elec- 
tricity in, 54.0; forms of, 531; 
morbid anatomy, 531; paralysis in, 
534, 540; prognosis, 538; severity 
of seizure, causes of , 533; temper- 
ature in, 533; treatment, general, 
539; types of, 533; venesection in, 

539- 

Cerebral hypersemia, 530. 

Cerebral palsies of children, 549; diff. 
diagn. fr. infantile spinal paraly- 
sis, 580. 

Cerebral softening, 541. 

Cerebral syphilis, diff. diagn. fr. 
chronic periencephalitis, 404. 

Cerebral typhus, see cerebro-spinal 
meningitis, 163. 

Cerebrasthenia, 429. 

Cerebritis, see encephalitis, 554. 

Cerebro-spinal meningitis, 163; abor- 
tive form of, 167; cephalalgia in, 
167; complications of, 169; con- 
tagiousness of, 163; convulsions 
in, 165, 167; cutaneous hyperaes- 
thesia in, 167; deafness in, 168; 
diagnosis, 169; diff. diagn. fr. in- 
fluenza, 147, 170; — — fr. per- 
nicious malarial fever, 170; 

fr. rheumatic fever, 170; fr. 

scarlet fever, 170; fr. second- 
ary meningitis, 170; — — fr. 

82 



small-pox, 170; fr. tubercu- 
lar meningitis, 169; — — fr. 

typhoid fever, 29, 170; fr. 

typhus fever, 170; eye-symptoms 
in, 168; forms of, 166, 167; ful- 
minant type of, 167; infectious- 
ness of, 163; intermittent type, 
167; micro-organisms of, 164; 
phenacetine in, 171; sequels of, 
169; spinal pains in, 167; treat- 
ment, 170; typhoid condition in, 
166; vertigo, 168. 

Cervical pachymeningitis, 571. 

Cervical vertebrae, caries of, cause of 
compression myelitis, 602. 

Cervico-brachial neuralgia, 498. 

Cervico-occipital neuralgia, 498. 

Cestodes, diseases due to, 1265. 

Chalicosis, 1010. 

Chalk-stones in gout, 347, 348. 

Chalmoogra oil in leprosy, 306. 

Champagne in epid. influenza, 149. 

Chancre, initial sore of syphilis, 271. 

Charbon, see anthrax, 186. 

Charcot's crystals in blood of those 
dead from leukaemia, 1166. 

Cheese poisoning by, 678. 

Cheesy pneumonia, 216. 

Chiasma and tract, disease of, 622. 

Chicken-pox, see varicella, 141. 

Children, constipation in, 862; con- 
vulsions in, 467; diabetes in, 358, 
363, 369; diarrhoea in, 826; bron- 
cho-pneumonia in, 227, ion; 
pneumonia in, 1004; rheumatism 
in, 329; tuberculosis of mesenteric 
glands in, 222. 

Chlorosis, 1154; age in, 1155; amenor- 
rhcea in, 1156; blood in, 1157; 
diet in, 11 58; digestive symptoms, 
1 156; heart symptoms of, 1157; 
heredity in, 1155; Sir Andrew 
Clark's theory of auto-intoxica- 
tion in, H55; Virchow's theory 
of, 1 155; symptoms, 1156; treat- 
ment, 1 158. 

Chlorosis rubra, 1156. 

Choked disk, 621. 



1298 



Cholangitis, 911. 

Chobelithiasis, 908; biliary colic in, 
909; chemical solvents in, 913; 
cholesterine stones, 909; composi- 
tion, 909; jaundice in, 909; lime- 
stones, 909; olive-oil treatment of, 
913; pigment-stones, 909; surgi- 
cal treatment of, 913. 

Cholera Asiatica, 189. 

Cholera infantum, 829. 

Cholera morbus, 813; cramping in, 
814; collapse of, 819; treatment, 
Si 9; diff. diagn. fr. Asiatic chol- 
era, 818; tosins from intestines a 
possible cause of, 813. 

Cholera nostras, see chol. morb., 813. 

Cholera sicca, 193, 194. 

Cholera, typhoid, 193. 

Choleraic conditions, differentiation 
from dysentery, 205. 

Cholerine, a mild form of Asiatic 
cholera, 193. 

Cholesterine in biliary calculi, 909. 

Chorea, acute, 472; choreic move- 
ments, H. C. Wood's definition 
of, 472; diagnosis, 477; diff. diagn. 
fr. habit-spasms, 477; — — fr. 
hysteria, 477; fr. paramyo- 
clonus multiplex, 477; electricity 
in, 478; frequent association with 
simple endocarditis, 1058; heart- 
symptoms of, 475; pain in, 475; 
psychical phenomena, 475; preg- 
nancy a cause of, 473; reflex 
causes, 473; rheumatism and 
chorea, relation of, 473; symp- 
toms, 474; treatment, 477. 

Chorea, chronic, 482; electrical, 481; 
hereditary {Huntingdon's), 482; 
major, 481; pandemic, 481; reflex, 
480; rhythmic, 483; spastic, 482; 
Sydenham's, 472. 

Chloride of lime in disinfection of 
cholera-stools, 196. 

Chlorine-fumigation for disinfection 
of rooms, 108. 

Chovestek' s symptom in tetany, 484. 

Chronic amygdalitis, 734. 



Chronic diffuse meningo-encephalitis, 
see chronic periencephalitis, 400. 

Chronic dysentery, 203. 

Chronic osteo-arthritis, 340. 

Chyluria, 1201. 

Ciliary muscle, paralysis of, 623. 

Cincture feeling in lesions of cord, 
564- 

Circular insanity, 422. 

Circumflex nerve, diseases of, 639. 

Cirrhosis of: kidney, 1225; liver, 890; 
lung, 1008; pancreas, 920; ventri- 
c'uli, 763. 

Cirsoid aneurism, 1133. 

Clavus hystericus, 442. 

Claw hand (main en griffe), 571. 

Clergymen's sore throat, 708. 

" Climate " a relative term, 246. 

Climate in consumption; when change 
no longer of value, 246. 

" Clubbed fingers, " 1068. 

Clownism in hysteria, 438. 

Cocainism, 674. 

Cocain-spray in dysphagia of laryn- 
geal tuberculosis, 261; in irritable 
throat of epidemic influenza, 160. 

Coccidium oviforme, 1263. 

Coccydynia, 499. 

Cceliac affection (Gee), 833. 

Coffee-ground vomit, 788, 797. 

Colic, appendicular, 845; biliary, 909; 
lead — , 668; mucous — , 850; renal 
— , 1240. 

Colic in angio-neurotic oedema, 644. 

Colic in purpura, 387. 

Colica, pictonum, 668. 

Colitus, 817. 

Colle's law, 270. 

Colon, cancer of transverse, diff. 
diagn. fr. cancer of pancreas, 922. 

Coma of: acute yellow atrophy, 884; 
alcoholic intoxication, 661; apo- 
plexy, 532, 533; diabetes, 362; 
epilepsy, 455; heat-exhaustion, 
681; ursemia, 1209. 

Coma of epilepsy, diff. diagn. fr. cere- 
bral apoplexy, 538. 



1299 



Coma of opium poisoning, diff. diagn. 
fr. cerebral apoplexy, 538. 

Comatose form of pernicious malarial 
fever, 73. 

Coma vigil of typhoid fever, 26; 
typhus, 42. 

Comma bacillus of Koch, 189. 

Compensation in valvular disease, 
1080, 1084. 

Compressive myelitis, 602; diagnosis, 
604; motor symptoms of, 603; 
sensory symptoms of, 602; treat- 
ment of, 604. 

Concentric hypertrophy of the heart, 
1092. 

Condylomata, 274. 

Confusional insanity, 413; delirium of, 
413; delusions of , 413; speech of, 
413; vaso-motor weakness in, 413. 

Congenital cystic kidney, 1247. 

Congenital syphilis, 283. 

Congestion of the kidneys, 1192. 

Congestion of lungs, 993. 

Conjugate deviation of the eyes, 626; 
in cerebral haemorrhage, 536. 

Consecutive nephritis, 1233. 

Constipation in chronic catarrhal en- 
teritis, 816. 

Consumption, see tuberculosis, 210. 

Contracted kidney, 1225. 

Contagious carbuncle, see anthrax, 
186. 

Contractures in hysteria, 440; myeli- 
tis of anterior horns, 580. 

Convulsions of: acute yellow atrophy, 
884; alcoholism, 665; chronic 
Bright 1 s disease, 1223, 1228; epi- 
lepsy, 454; hysteria, 436; lead- 
poisoning, 670; meningitis, 519, 
523; uraemia, 1209. 

Convulsions, infantile, 467. 

Convulsive "tic," 481. 

Copper test for sugar, 364. 

Copper, sulphate of, for disinfecting 
excreta, 195. 

Coprobalia, 482. 

Coproztasis a cause of intestinal ob- 
struction, 854. 



Cor adiposum, 1105. 

Cor bovinum, 1073, 1094. 

Cor villosum, 1048. 

Coral calculi, 1239. 

Coronary arteries, aneurism of, 1143; 
obstruction of, in true angina pec- 
toris, 1 1 20. 

Corrigan's button-hole constriction, 
1070. 

Corrigan's pulse, 1073, 1076, 1119. 

Corset-liver, 903. 

Cortical epilepsy, 458. 

Coryza acute, see acute nasal catarrh, 

945- 
Coup de solbeil, 680. 
Cramp, writer's, 490. 
Cramping of legs in Asiatic cholera, 

192. 
Cranial nerves, diseases of, 619. 
Cranio-tabes, a sign of rickets, 375. 
Cretinism, sporadic, 1184. 
Crises in angio-neurotic cedema, 644; 

in locomotor ataxia, 593. 
Crossed or alternating hemiplegia, 

535- 
Croup, membranous, 968; spasmodic, 

959- 

Croup, diff. diagn. between false and 
and true, 971. 

Croupous enteritis, see follicular enter- 
itis, 830. 

Croupous pneumonia, 998. 

Cruveilhief 's palsy, 606. 

Cullen's theory of the nervous origin 
of gout, 347. 

Curschmann's spirals, 991. 

Cutaneous complications in rheumatic 
fever, 328. 

Cyanosis in congenital heart-disease, 
1068, 1071, 1081; in pulmonary 
emphysema, 1018. 

Cycloplegia, 623. 

Cyclothymentia, 422. 

Cynanche maligna, see diphtheria, 81. 

Cynanche contagiosa, see diphtheria, 
81. 

Cynanche tonsillaris, see acute tonsil- 
litis, 729. 



1300 



INDEX. 



Cynobex hebetica, a symptom of hys- 
teria, 443. 

Cysticercus-disease, 1269. 

Cystine calculi, 1240. 

Cystimuria, 1203. 

Cystitis, acute, 1250; abscess in, 1252; 
chronic, 1252; diphtheritic, 1251; 
from retained urine, 1250; gan- 
grenous, 1 251; mucous cloud in, 
1252; spasms of sphincter in, 1251; 
urine in, 1251; vesical tenesmus 
in, 1 251; washing-out of bladder 
in, 1253. 

Cystitis with distension of bladder, 
diff. diagn. fr. acute peritonitis, 
93o. 

Cytozoa, 1263. 



Dancing mania, 481, 483. 

Dandy-fever (dengue), 79. 

Deafness in: cerebro-spinal-meningi- 
tis, 169; measles, 122; /Meniere's 
disease, 631; scarlet fever, 106, 117. 

Debility, nervous, see neurasthenia, 
428. 

Degeneration, reaction of, 579. 

Deglutition, difficult, see dysphagia. 

Deglutition pneumonia, ion, 1019, 
1020. 

Delirium tremens, 663; d. cordis, 11 19. 

Dementia paralytica, see chronic peri- 
encephalitis, 400. 

Demodex folliculorum, 1107, 1287. 

Dengue-fever, 79; diff. diagn. fr. La 

Grippe, 80; fr. rheumatism, 

80; fr. typhoid fever, 53; — 

— fr. yellow fever, 53; eruptions 
of skin in, 79; gastro-intestinal 
type of, So; pains in, 79; symp- 
toms of, 79; treatment, 80. 

Dentition in congenital syphilis, 2S4; 
in rickets, 376. 

Dermatitis, acute exfoliating, diff. 
diagn. fr. scarlet fever, 106. 

Desquamation in: measles, 121; ru- 
bellae, 128; scarlet fever, 103; 
small-pox, 131; typhoid fever, 26. 



Delweiler'' s flask, a receiver of expec- 
toration, 242. 

Diabetes insipidus, 369; complications, 
370; diagnosis, 371; diff. diagn. fr. 

— mellitus, 371; f r. hysteria, 

371 ; heredity in, 369; shock a cause 
of, 369; urine in, 370. 

Diabetes mellitus, 357; appetite in, 
361; blood-changes in, 360; com- 
plications, 361; cutaneous affec- 
tions in, 362, 367; diabetic coma, 
362; diagnosis, 363; diet in, 365; 
eye-and-ear symptoms of, 362; 
heart, changes in, 360; heredity 
in, 357; kidneys, changes in, 360; 
liver, changes in, 359; lungs, 
changes in, 360; nervous impair- 
ment, a cause of, 358; pancreatic 
disease and, 359; peripheral 
neuritis in, 362; pregnancy in, 
363; pulmonary complications of, 
361; Purdy on the nature of, 
358; race in, 358; renal complica- 
tions of, 361; tests for sugar in 
urine of, 364; thirst in, 361; urine 
in, 360. 

Diabetic coma, 362. 

Diaceturia, 1206. 

Diaphragm, spasms of, 638. 

Diaphragmatic hernia, diff. diagn. fr. 
pneumothorax, 1038. 

Diarrhoea, see catarrhal enteritis, 812. 

Diastolic collapse in adhesive pericar- 
ditis, 1056. 

Diet in: acute nephritis, 12 [7; chloro- 
sis, 1158; constipation, 863, 865; 
diabetes, 365; diphtheria, 92; 
dysentery, 207; gout, 353; infan- 
tile diarrhoea, 835; obesity, 686; 
scurvy, 383; typhoid fever, 33; 
valvular disease of heart, 1092; 
yellow fever, 55. 

DielVs crises in movable kidney, 1190. 

Digestive tract, syphilis of, 282. 

Digitorum nodi, in chronic arthritis, 
342. 

Dilatation of: bronchi, 988; heart, 
1096; stomach, 781, 11 90. 



1301 



Diphtheria, 8r; anti-toxin in, 99; com- 
municability of, 81; complica- 
tions, 87; convulsions in, 84; di 
agnosis of, 88; diff. diagn. fr. 

epidemic tonsillitis, 88; fr. 

follicular tonsillitis, 88; fr. 

membranous laryngitis, 88; 

fr. scarlatinal sore throat, 89; diet 
in, 92; diphtheritic membrane, 83; 
disinfection in, 91; extensive into 
ear, 85; — into larynx, 85, 94; 
into nares, 85 ; Klebs-Lceffler bacil- 
lus, constitutional effects caused 
by toxines of, 84; descrip- 
tion, 82, 83; local action of, 

83, 84; local lesion, extension of, 
85, 89; local treatment of cutane- 
ous form, 95; of laryngeal 

form, 94; of nasal diphtheria, 

92; of pharyngeal form, 92; 

of post-diphth. paralysis, 95; 

mortality in, 89; naso-pharyngeal 
catarrh and diphth., 83, 90; 
prophylaxis of, 90; relative of local 
to constitutional disease, 86, 87; 
sequels of, 87; specific poison of, 
82; systemic infection, forms of, 

86; , skin symptoms in, 86; 

throat-symptoms in early stage, 
84; treatment, 90. 

Diphtheria-toxin in neuritis, 618. 

Diphtheritic form of dysentery, 203. 

Diphtheritic sore throat, see herpetic 
pharyngitis, 717. 

Diplococcus pneumoniae, 999. 

Dipsomania, see chronic alcoholism, 
461. 

Dipylidium caninum, 1266. 

Disinfection in diphtheria, 90, 91; ery- 
sipelas, 179; small -pox, 136, 137, 
138; typhoid fever, 30, 31; yellow 
fever, 54. 

Dissecting aneurism, 1133, 1145. 

Distomiasis, [275. 

Distoma, 1275. 

Dittrich's plugs, 983. 

Diuretin in dyspnoea and dropsy of 
valvular disease, 1091. 



Diverticula, 745. 

Diver's paralysis, 489. 

Dochmius duodenalis, 1278. 

Dorsodynia, 336. 

Dracontiasis, 1279. 

Dropsy in acute nephritis, 1214; in 
valvular disease of heart, 1068, 
10S1. 

Drug-eruptions, diff. diagn. fr. mea- 
sles, 123. 

Dry cupping in headache fr. cerebro- 
spinal meningitis, 171. 

Dry heat in itching of erysipelas, 180. 

Dryness of skin in acute nephritis, 
1215. 

Dubini's disease, 481. 

Duchenne' 1 s paralysis, 609. 

Duodenitis, 817. 

Dysacursis, 630. 

Dysentery, 199; complications, 204; 
diagnosis, 205; diff. diagn. fr. 

cancer of rectum, 205; fr. 

choleraic conditions, 205 ; f r. 

diarrhoea, 205; fr. intussus- 
ception in children, 205; fr. 

syphilis of rectum, 205; fr. 

typhoid fever, 205; forms of, 200; 
infectious character of, 200; micro- 
organisms of, 200; mortality of, 
206; equals, 204; treatment, 206. 

Dysentery, amoeboid, 201; abscesses 
of liver in, 202; ulcers of , 201. 

Dysentery, catarrhal, symptoms of, 
200. 

Dysentery, chronic form, 203. 

Dysentery, pseudo-membranous form 
of, 203. 

Dyspepsia, see gastric catarrh, 754, 
761. 

Dysphagia in cancer of the oesophagus, 
747; hysteria, 443; oesophagus, 
741; oesophageal spasm, 750; 
cesoph. structure, 743; pericardial 
effusion, 1050; rabies, 292; thoracic 
aneurism, 1135; tubercular laryn- 
gitis, 260. 

Dyspnoea in mitral insufficiency, 1080; 
in valvular disease, 1080. 



1302 



INDEX. 



Dystrophies, muscular, 652. 

Ear complications in scarlet fever, 106, 

117, 120. 
Early paranvia, 419. 
Ebstein's diet of the obese, 686. 

Eburnation of joints in chronic arth- 
ritis, 342. 

Eccentric hypertrophy of the heart, 
1092. 

Echinococcus disease, 1270; of brain, 
1274; of lungs and pleura, 1273; 
of kidney, 1273; of liver, 1272; of 
peritonaeum, 1274. 

Ecistrongylus gigas, 1280. 

Echokinesis, 482. 

Echolalia, 482. 

Eclampsia, see infantile convulsions, 
467. 

Eczema a sign of lithaemia, 350. 

Electrical chorea, 481. 

Electricity in: actinomycosis, 312; 
acute chorea, 478; angina pectoris, 
1 124; convalescence from cerebro- 
spinal meningitis, 172; constipa- 
tion, 863; diabetes, 369; epilepsy, 
463; enuresis, 1259; exophthalmic 
goitre, n83;gastralgia, 773; goitre, 
1 178; gonorrhceal rheumatism, 
337; hay-fever, 953; insomnia, 511, 
neuralgia, 502; paralysis, 95, 172, 
540; rheumatic arthritis, 345. 

Electrolysis in aneurism, 1140. 

Elephantiasis graecorum, see leprosy, 
302. 

Emaciation in anorexia nervosa, 443; 
gastric cancer, 796; oesophageal 
cancer, 748; oesophageal stricture, 
743; pulm. tuberculosis, 234. 

Embolic abscesses, 183. 

Embolism and aneurism in cardiac 
disease, 1059, 1061, 10S2. 

Embryocardia, 1098. 

Emphysema, 1016; bronchitis in, 981, 
101S; cyanosis in, 1018; diff. 
diagn. fr. pneumothorax, 1038; 
— — fr. whooping cough, 159; 
dyspnoea in, 1018; forms of pul- 



monary — , 1016; treatment of, 
1019. 

Empyema, 1029. 

Empyema necessitatis, 1031. 

Encephalitis, suppurative, 554. 

Encephalopathy of lead-poisoning, 
670. 

Endemic neuritis, 615. 

Endocarditis, acute or simple, 1058; 
acute articular rheumatism a com- 
mon cause of, 1058; chorea, fre- 
quent association with, 1058; ton- 
sillitis, connection with, 1058; diff. 
diagn. fr. malignant form, 1063; 
vegetations in, 1058. 

Endocarditis a complication of rheu- 
matic fever, 327; of scarlet fever, 
105. 

Endocarditis, chronic, 1065; diphthe- 
ritic, 1060; infectious, 1060; in- 
terstitial, 1065; mycotic, 1060; 
sclerotic, 1065; ulcerative, 1060. 

Endocarditis, malignant, 1060; diff. 

diagn. fr. pyaemia, 1063; fr. 

rheumatic fever, 1063; — — fr. 

simple endocarditis, 1063; fr. 

typhoid fever, 1063; embolism in, 
1062; types of, 1062. 

Endocardium, diseases of, 1057. 

Enteralgia, 867; diff. diagn. fr. intes- 
tinal obstruction, 869; — — fr. 
rheumatism of abdominal mus- 
cles, 869. 

Enteric fever, see typhoid fever, 19. 

Enteritis, catarrhal, 810; acute form, 
812; chronic form, 814; [an ex- 
pression of a cachexia, 815; con- 
stipation in, 816; corneal ulcera- 
tion in camp-diarrhoea, 817; diet 
in, 819; injections of nitrate of 
silver in, 820]; diagnosis, 817; 
diff. diagn. fr. dysentery, 818; — 

— fr. intestinal obstruction, 859; 

— — fr. peritonitis, 818; fr. 

typhoid fever, 818. 

Enteritis in children, 826; cleanliness 
in the treatment of, 834; diet in, 
835; forms of, 828 [acute dyspep- 



1303 



tic, 829; acute entero- colitis, 830; 
cholera infantum, 829; chronic 
diarrhoea, 832]; treatment of, 
834, 836, 837. 

Enteritis phlegmonous, 850. 

Enteritis, pseudo-membranous, 850. 

Entero-colitis, 830; diff. diagn. fr. 
acute peritonitis, 929. 

Enteroliths a cause of intestinal ob- 
struction, S54. 

Enteroptosis {Glenard), 11 90. 

Entero-stenosis, see intestinal obstruc- 
tion, 852. 

Enuresis, 1257. 

Eosinophils in leukaemia, 11 67. 

Ephemeral fever, see febricula, 312. 

Epidemic catarrhal fever, see epidemic 
influenza, 143. 

Epidemic haemoglobinuria, 1196. 

Epidemic influenza, 143; complica- 
tions of, 146; contagiousness of, 
144; diagnosis, 147; diff. diagn. 
fr. cerebro-spinal meningitis, 147, 
170; — — fr. dengue fever, 80; 

fr. simple catarrh, 148; — 

— fr. typhoid fever, 147; 

fr. gastro-intestinal catarrh, 145; 
micro-organisms of, 143; modes 
of infection, 143; mortality of, 
148; nervous symptoms, 145; 
phenacetine in, 149; pneumonia 
a complication of, 146; respira- 
tory symptoms in, 145; salipyrine 
in, 149; sequels of, 146; treatment 
of, 148; types of, 146. 

Epidemic meningitis diff. diagn. fr. 
cerebro-spinal meningitis, 163. 

Epidemie parotitis, 151; complications, 
153; contagiousness of, 151; diag- 
nosis, 154; diff. diagn. fr. lymph- 
angitis, 154; fr. retro-pharyn- 

geal abscess, 154; orchitis in, 154, 
155; secondary — , 153; treatment, 
154. 

Epidemic tonsillitis, diff. diagn. fr. 
diphtheria, 88. 

Epilepsy, 452; age in, 453; diagnosis, 
459; diff. diagn. fr. hysteria, 460; 



fr. uraemic convulsions, 459; 

frequency of paroxysms, 458; 
grand mal, 453 [aura in, 453; con- 
vulsions in, 453; symptoms, 454]; 
heredity in, 452; Jacksonian — , 
458,461; malingering, 459; mania 
in, 457; nocturnal form, 455; petit 
mal, 455; prognosis, 460; reflex 
causes of, 452; treatment of, 461. 

Epilepsia precursiva, 456. 

Epileptic equivalents (Samt), 457. 

Epileptic insanity, 405. 

Epileptic mania, 457. 

Epileptiform convulsions in uraemia, 
1209. 

Epistaxis, 955; tamponing in, 955. 

Erb's mj'otoni creaction, 657. 

ErichseWs disease, see traumatic 
neurosis, 487. 

Erysipelas, 176; abscesses in, 178; 
aetiology of, 176; complicating 
nodular leprosy, 305; complica- 
tions of, 179; contagiousness of, 
176; diagnosis, 179; extension of 
process, 178; micro-organisms of, 
177; treatment, 179. 

Eschar, sloughing, in hemiplegia, 534. 

Essential paralysis of infants, see my- 
elitis of antihorus, 577. 

Eustrongylus gigas, 1 280. 

Exanthematic typhus, see typhus 
fever, 40. 

Exophthalmic goitre, 1179; cardiac 
hypertrophy in, 1180; electricity 
in, 1 1 83; eye-symptoms of, 1181; 
maebius on the causation of, 1180; 
nervous symptoms of, 1181; pro r 
trusionof eye-balls in, 1 181; surg- 
ical methods in, 1 1 83; tachycardia 
in, 1 1 80; thyroid enlargement in, 
1 181; thyroid gland, treatment of, 
1183. 

Eye, affections of motor nerves, 623; 
of fourth nerve, 624; of sixth 
nerve, 624; of third nerve [aniso- 
coria, cycloplegia, iridoplegia, 
paralysis, ptosis], 623. 

Eye, motor-paralysis of, 625. 



1304 



Eye-strain in migraine, 492; in epi- 
lepsy, 452. 

Eyes, conjugate deviation, 536. 

Expectoration of consumptives, care 
of, 242. 

Facial hemiatrophy, 648. 

Facial nerve, lesions of, 627; paralysis 
of, 627; spasms of, 629. 

Facies myopathique in progressive 
muscular atrophy, 655. 

Faecal accumulations a cause of intes- 
tinal obstruction, 854. 

Famine fever, see typhus fever, 40. 

Farcy, see glanders, 306, 307. 

Farcy buds, 30S. 

"Fasting girls," 443. 

Fatty degeneration in anaemia, 11 61; 
arteries, 1128; heart, 1105; liver, 
896. 

Fatty stools, 917. 

Febricula, 312; diagnosis, 313, 

Feeding in laryngeal tuberculosis, 261. 

Fehling's test for sugar, 364. 

Fermentation fever, a form of septicae- 
mia, 182. 

Fermentation test for sugar, 364. 

' ' Festination ' ' a symptom of paraly- 
sis agitans, 486. 

Fetid stomatitis, 695. 

Fever-and-ague, see malarial fever, 58. 

Fibrous bronchitis, 986; — pneu- 
monias, 998. 

Fibroid heart, 1102. 

Fifth nerve, lesions of, 626. 

Filaria hominis sanguinis, 1280. 

Filaria Loa, 1281. 

Filariasis, 1280. 

Fish, poisoning by, 678. 

Fistula, biliary, from gall-stones, 911. 

Fistula in ano in tuberculosis, 241. 

Flea-bite, T288. 

Floating kidney, 11 89. 

Flukes, diseases caused by, 1275. 

Focal lesions in spinal cord, 563. 

Foetus, endocarditis in, 1065; syphilis 
in, 283; white pneumonia of, 280. 

Follicular colitis, 200. 



Follicular dysentery, 200. 

Follicular tonsillitis, 729; diff. diagn. 
fr. diphtheria, 8S. 

Foot-drop, 614. 

Fortification lines of migraine, 492. 

Fourth nerve, lesions of, 624. 

French measles, see rubella, 127. 

Friedreich's ataxia, see hereditary 
ataxia, 599. 

Friedreich's "diastolic collapse" in 
adherent pericardium, 1056. 

Fuller's solution in pain of gout, 354; 
in rheumatic fever, 330. 

Gait in: locomotor ataxia, 592; paraly- 
sis agitans, 486; pseudo-hyper- 
trophic muscular atrophy, 653; 
peripheral neuritis, 613: spastic 
peraplegia, 586; Thomsen's dis- 
ease, 656. 

Galacturia, 1201. 

Gall-bladder, cancer of, 915; diff. di- 
agnosis fr. cancer of liver, 901. 

Gall-bladder, dilatation of, diff. diagn. 
fr. cancer of liver, 901. 

Gall-bladder, obstruction of, 914. 

Gall-ducts, cancer of, 914; occlusion 
from gall-stones, 911, 912; steno- 
sis of, 915. 

Galloping consumption, see acute 
pneumonic phthisis, 225. 

Gallop-rhythm, 1098. 

Gall-stones, see cholelithiasis, 908; a 
cause of intestinal obstruction, 
854; diagnosis of, 858; diff. diagn. 
fr. hepatic abscess, 890; gall-stone 
colic, diff. diagn. fr. pain of gas- 
tric ulcer, 790. 

Gangrene in diabetes, 362; in intus- 
susception, 853; in pneumonia, 
1005; of mouth, 87, 696; pulmo- 
nary, 1020; typhus fever, 43. 

Gangrene, pulmonary, diff. diagn. fr. 
pulmonary tuberculosis, 240. 

Gangrenous stomatitis, 696. 

Garrod's theory of gout, 347. 

Garrod's thread-test for uric acid, 352. 

Gastralgia, 767; diagnosis, 768; diff. 
diagn. fr. acute gastric catarrh, 



INDEX. 



1305 



758; fr. gastric ulcer, 790; — 

— fr. organic disease, 768; elec- 
tricity in, 773; pain in, 767; per- 
versions of appetite in, 768; treat- 
ment of, 768. 

Gastrectasis, see dilatation of stomach, 
781. 

Gastric catarrh, acute, 754; diff. diagn. 
fr. abortive forms of typhoid 

fever, 758; acute peritonitis, 

929: fr. gastralgia, 758; di- 
arrhoea in, 755; diphtheritic form, 
757; gastric fever a form of, 755; 
gout and rheumatism, relation to, 
754; of drunkards, 756; of infants, 
756; pain in, 755; phlegmonous, 
757; toxic gastritis, 756, 758. 

Gastric catarrh, chronic, 761; cirrho- 
sis ventriculi in, 763; diagnosis, 
764; diff. diagn. fr. atonic dys- 
•pepsia, 764; — — fr. cancer of 
stomach, 764, 799, 800; heart-burn 
in, 763; jaundice in, 764; lavage 
in, 765; pharyngeal catarrh in, 
764; phthisis ventriculi, 763; scle- 
rotic gastritis in, 763; treatment, 
764. 

Gastric fever, 755. 

Gastric crises in locomotor ataxia, 

593- 

Gastric ulcer, 785; diff. diagn. fr. 
cancer of stomach, 799, 800. 

Gastritis, see gastric catarrh, 754, 761. 

Gastritis toxica, see acute gastric ca- 
tarrh, 756, 758. 

Gastrodynia, see neuroses of stomach, 
767. 

Gastromalacia, 808. 

Gastrorrhagia, see haemorrhage from 
stomach, 802. 

Gastroxynsis (Rossbach), 771. 

General paresis, see chronic perience- 
phalitis, 400. 

General progressive paralysis, see 
chronic periencephalitis, 400. 

Genito-urinary system, tuberculosis of , 
266; syphilis of, 283. 

German measles, see rubella, 127. 



Giant urticaria, see angio-neurotic 
cedema, 644. 

Gilbert's syrup in congenital syphilis, 
. 285. 

Gilles de la Tourette's disease, 481. 

Gin-drinker's liver, see cirrhosis of 
liver, 890. 

Girdle-feeling in locomotor ataxia, 
59i- 

Glanders, 306; blood-poisoning in, 
308; blood-serum treatment of, 
309; diff. diagn. fr. tuberculosis, 
308; — — fr. van ota, 308; erup- 
tion of, 307; general infection, 
307; inoculation, 307; local in- 
fection, symptoms of, 307; post- 
mortem changes, 308; treatment, 
308. 

Glioma of brain, 556. 

Glissonian cirrhosis of liver, 891. 

Glisson's sheath, syphilis of, 281. 

Globus hystericus, 437. 

Glomerulo-nephritis, 1213. 

Glossitis, 701. 

Glosso-labia-laryngeal paralysis, see 
bulbar paralysis, 609. 

Glosso-pharyngeal nerve, lesions of, 
632. 

Glottis, oedema of, see cedematous 
laryngitis, 964. 

Glossy skin in polyneuritis, 614. 

Glycosuria, 360; gouty, 351. 

Goitre, 1176; electricity in, 1178; press- 
ure, effects of, 1177; thyroid- 
gland extract, treatment of, 1178; 
varieties of, 1177. 

Goitre, exophthalmic, 1179. 

Gonorrhoeal arthritis, 339. 

Gout, 346; acute form, 349; alcoholic 
stimulants, relation to, 346; chalky 
deposits in, 347; chronic form, 
350; Cull en's theory of nervous 
origin of, 347; diff. diagn. from 

arthritis deformans, 352; fr. 

articular rheumatism, 344, 351; — 
— fr. chron. rheumatism, 329, 351; 
diet a cause of, 346; diet in, 353; 
forms of, 349; heart in, 348; he- 



1306 



INDEX. 



redity in, 346; irregular form of, 
350; kidneys in, 348; lithaemic 
diathesis, 350; liver in, 348; mor- 
bid anatomy of, 347; pain, relief 
of, 354; respiratory organs in, 34S; 
stimulants in, 354; suppressed 
gout, dangers from, 350; treat- 
ment, 352; uric acid, theory of, 
347- _ 

Gouty kidney, see chronic interstitial 
nephritis, 1225, 1226. 

Grandeur, delusions of, 396, 402. 

Grand mal, 453. 

Granular kidney, 1225. 

Gravel, renal, 1239. 

Grave's disease, see exophthalmic 
goitre, 1 1 79. 

Gray degeneration of. posterior col- 
umns, see locomotor ataxia, 589. 

Gray infiltration of Lcsnnec, 216. 

Green sickness, see chlorosis, 1156. 

Gregarinidae, parasitic, 1263. 

Grippe, la, see epidemic influenza, 
143- 

Guaiacum test for blood in urine, 1 194. 

Guinea-worm disease, 1279. 

Gummata, syphilitic, 275. 

Gums, blue line on, from lead-poison- 
ing, 669. 

Habit-spasms, 4Sr. 

Habit, apoplectic, 530; consumptive, 
214, 

Haematemesis, S02; treatment, 793. 

Haematidrosis, 444. 

Haematochyluria, 1280. 

Haematomyelia, 572. 

Hsematozoa of malaria, 58, 59. 

Haematuria, 1 193; endemic, of Egypt, 
of acute nephritis, 1214; of pul- 
monary tuberculosis, 235; of renal 
calculus, 1241; of tuberculosis of 
kidney, 1193. 

Haemoglobin, reduction of, in chloro- 
sis, 1 157. 

Haemoglobinuria, 1196; in Raynaud's 
disease, 643. 

Haemopencardiurn, 1057. 



Haemophilia, 389; anaemia from, 390; 
direct causes of, 390; inherited 
tendency in, 389; marriage in 
persons predisposed to it, 390; 
slight injuries in, 390; treatment, 
390. 

Haemoptysis, 995; diff. diagn. fr. 
bleeding of gastric ulcer, 790. 

Haemorrhage, cerebral, 530; gastric, 
802; intestinal, 874; pulmonary, 
994; in acute yellow atrophy, 884; 
in cirrhosis of liver, 893; in con- 
tracted kidney, in diphtheria, 87; 
in gastric cancer, 797; in gastric 
ulcer, 788; in haemophilia, 390; in 
hysteria, 442, 444; in leukaemia, 
1167; in malaria, 73; in the new- 
born, 390; in purpura haem., 385, 
387; in scarlet fever, 104; in 
scurvy, 382; in small-pox, 134; in 
typhoid fever, 35; in yellow fever, 
51, 52; into heart-sac, 1057; into 
pancreas, 917; into spinal cord, 
572; into ventricles of brain, 531. 

Haemorrhage diathesis, 389. 

Haemorrhoids, therapeutics of, 866, 
867. 

Haemothorax, 1036. 

H aim's test for sugar, 364. 

Hand in general paresis, effects upon 
its efficiency, 402. 

Hard chancre or initial sore, 27 r. 

Harrison' s groove, a sign of rickets, 

375- 
Harvest-bug, 12S7. 
Hay-asthma, see hay-fever, 952. 
Hay-fever, 952; climate in, 953; diff. 

diagn. fr. measles, 123; electricity, 

953- 

Headache from cerebral tumor, 557; 
of cerebral syphilis, 280; of mouth- 
breakers, 737; of typhoid fever, 
21, 27; of uraemia, 1208. 

Heart, aneurism of, 1107. 

Heart, diseases of: acute myocarditis, 
1099; aneurism, 1107; atrophy, 
1098; degeneration of heart-mus- 
cle, 1 104; dilatation, 1096; dropsy, 



1307 



1056; endocarditis, malignant, 
1060; endocarditis, simple, 1058; 
fatty, 1 105; fibroid heart, 1102; 
hypertrophy, 1092; rupture of, 
1 108; tumors of, 1109; valvular 
disease of, 1065. 

Heart-failure in diphtheria, 88. 

Heat and nitric acid test for albumin, 
1200. 

Heat-exhaustion, 679; ardent con- 
tinued fever, a form of, 682; fall 
of temperature in, 679; thermic 
fever, 680 [definition of, 680; ele- 
vation of temperature in> 681; 
morbid anatomy of, 680]; treat- 
ment of, 683. 

Hebephrenia, 419. 

Heberden's nodosities, 342. 

Hebrews, prevalence of diabetes 
among them, 358. 

Heller's test for albumin, 1199. 

Helminthiasis, 1265. 

Hemiansesthesia in cerebral hsemor- 
.rhage, 536; hysteria, 441; uni- 
lateral cord lesions, 566. 

Hemianopsia, 622. 

Hemicrania, 492. 

Hemiplegia, 535, 566; crossed, 535. 

Hemiplegia, infantile, 549; aphasia in 
right-sided — , 550; epilepsy in, 
550; mental dulness in, 550, 551; 
post-hemiplegic movements, 550; 
in spastica cerebralis, 551. 

Hepatic abscess, 885; — enlargement, 
887, 888, 896, 900; — colic, 909. 

Hepatic colic, diff. diagn. fr. renal 
colic, 1242. 

Hepatitis, acute parenchymatous, 883; 
diff. diagn. fr. phosphorus-poison- 
ing, 885. 

Hepatitis, diffuse syphilitic, 281. 

Hepatitis, fibrous, 890; alcoholism in, 
891; atrophic cirrhosis, 892 [as- 
cites in, 893; gastro-intest. catarrh 
in, 893; splenic enlargement in, 
893]; diagnosis, 894; hypertrophic 
cirrhosis, 894; syphilis in, 891. 

Hepatitis suppurativa, S?5; diff. diagn. 



fr. fever of gall-stone, 890; fr. 

malarial fever, 889; enlargement 
of liver in, 888; jaundice in, 888; 
perforation in, 887; pulmonary 
involvement in 889. 

Hepatization of lung, 999, 1000; white, 
of foetus, 280. 

Hereditary ataxia, 599. 

Heredity in: diabetes insip., 369; diab. 
mell., 357; FreidreicK' s ataxia, 
599; gout, 346; haemophilia, 389; 
spastic paraplegia, 587; syphilis, 
269; tuberculosis, 212. 

Herpes zoster, 499. 

Hiccough, 638. 

High altitude in treatment of con- 
sumption, 245. 

Hippus, 492. 

Hodgkirts disease, 1169; anaemia in, 
1 171; bronzing of skin in, 1171; 
diff. diagn. fr. tubercular adenitis, 
1 172; lymphatic enlargement in, 
1170; lymphoid growths in, 1170; 
pressure, symptoms of, 1171; 
pruritus in, 1171; splenic enlarge- 
ment in, 1 170. 

Hcessli's law as to inherited tendency 
to haemophilia, 389. 

Hospital fever, see typhus fever, 40. 

Hunterian chancre, 271. 

Huntingdon' s chorea, 998. 

Hutchinson's teeth of congenital syph- 
ilis, 284. 

Hyaline casts in urine, 1207. 

Hydatid disease, 1270; of liver, 1272. 

Hydrencephaloid ( Marshall-Hall ) , 
830. 

Hydrocephalus, acute, 522. 

Hydrocephalus, chronic, 561. 

Hydrocephalic cry, 523. 

Hydronephrosis, 1236; diff. diagn. fr. 
ovarian tumor, 1238. 

Hydropencardium, 1056. 

Hydroperitonseum, see ascites, 938. 

Hydrophobia, see rabies, 291; diff. 
diagn. fr. tetanus. 299. 

Hydropneumothorax. 1037. 

Hydrotherapeutics in post-scarlatinal 



1308 



INDEX. 



nephritis, 109; in yellow fever, 
54- 

Hydrothorax, 1036. 

Hydruria, see diabetes insip., 369. 

Hymenolepsis diminuta, 1266; — 
nana, 1266. 

Hyperacrosis, 630. 

Hyperesthesia in: ataxia, 591; hys- 
teria, 441; rickets, 374; unilateral 
lesions of spinal cord, 566. 

Hyperosmia, 620. 

Hyperpyrexia in: hysteria, 444; peri- 
carditis, 1050; rheumatic fever, 
328; scarlet fever, 104, 109; thermic 
fever, 681, 682; tetanus, 299. 

Hyperuresis, 369. 

Hypnotics, 512. 

Hypochondriasis in sexual neuras- 
thenia, 429. 

Hypoglossal nerve, lesions of, 636. 

Hypostatic congestion of lungs, 994. 

Hysteria, 435; aura in, 436, 437; car- 
diac irritability in, 442; catalepsy 
in, 439; causation of, 435; clonic 
spasms in, 440; contractures in, 
440; convulsive form, 436; diff. 
diagn. fr. diabetes insip., 371; — 

— from epilepsy, 460; — — fr. 
locomotor ataxia, 595; — — fr. 
St. Vitus's dance, 477; — — fr. 
tetanus, 299; digestive disturb- 
ances, 443; epidemics of, 436; 
globus hystericus, 437; hallucina- 
tions in, 438; joint affections in, 
444; major convulsive form of, 
437; mental symptoms of, 444; 
minor convulsive form, 436; narco- 
lepsy in, 439; neuropathic tend- 
ency in, 435; non-convulsive form, 
440; paralysis in, 440; 'pos- 
ing" in, 438; race in, 435; respi- ! 
ration, disturbances of, 443; sen- 
sory disorders in, 441; sweating 
in, 444; temperature in, 444; treat- 
ment of, 445; tremors in, 441. 

Hysterical angina pectoris, 442; — 
anaesthesia, 441; — insanity, 406; 

— vomiting, 448. 



Hystero-epilepsy, 437. 
Hysterogenic points, 441. 

Ichthyol in rheumatic fever, 330. 

Ichthysmus, 678. 

Icterus, see jaundice, 904. 

Idiopathic anaemia of Addison, 1161. 

Idiopathic muscular atrophy, see pro 
gressive muscular atrophy, 652. 

Ilectis, 817. 

Ileo-typhus, see typhoid fever, 19. 

Ileus, see intestinal obstruction, 852. 

Impotence in diabetes, 361; in loco- 
motor ataxia, 593. 

Incarceration symptoms (Dietl), 1190. 

Indicanuria, 1204. 

Indigestion, acute, see acute gastric 
catarrh, 754. 

Infantile convulsions, 467; dentition a 
cause of, 468; lancing of gums in, 
470; laryngismus stridulus a form 
of local, 468; rickets a cause of, 
468; treatment, 470. 

Infantile paralysis, 577. 

Infantilism in congenital syphilis, 284. 

Infarcts in pysemia, 183. 

Inflation of bowel for intussusception, 

859- 

Influenza, epidemic, 143. 

Infusoria, parasitic, 1264. 

Ingravescent apoplexy, 533. 

Inhalation pneumonia, 1011, 1019, 
1020. 

Initial sclerosis of syphilis, 271. 

Insanity, see mental diseases, 393; 
therapeutics of, 422. 

Insects, parasitic, 1287. 

Insomnia, 509. 

Insular sclerosis of brain, 552. 

Intention tremors, 552. 

Intermittent fever. 60; infantile type, 
62; quinine in, 64; splenic enlarge- 
ment in, 60; temperature in, 61, 
62, 63; types, 63. 

Interstitial hepatitis, chronic, see 
fibrous hepatitis, 890. 

Intestinal colic, diff. diagn. fr. renal 
colic, 1242. 



1309 



Intestinal obstruction. 852; chronic, 
856; coprostasis a cause of, 854; 
diagnosis, 857; diff. diagn. fr. 
acute enteritis, 859; — ■ — fr. acute 

haem. pancreatitis, 858; fr. 

appendicitis, 859; fr. enter- 

algia, 869; enteroliths a cause of, 
854; functional, 854; gall-stones a 
cause of, 854; intestinal constric- 
tion a cause of, 856; intussuscep- 
tion a cause of, 853; lavage of 
stomach in, 859; location of seat 
of, 857; strangulation a cause of, 
S52; treatment, 859; tumors of in- 
testine a cause of, 854; volvulus a 
cause of, 853. 

Intestines, amyloid degeneration of, 
877; cancer of, 875; haemorrhage 
from, 875; ulceration of, S72. 

Intestinal hsemorrhage in typhoid 
fever, 22, 26; in ulceration, 873. 

Intestines, intussusception, 853; in- 
vagination, 853; strangulation, 
852; strictures, 853; tuberculosis, 
265. 

Intestines, perforation of, in typhoid 
fever, 25. 

Intussusception, 853; a cause of intes- 
tinal obstruction, 853; diagnosis, 
858; diff. diagn. fr. appendicitis, 
847; in children, diff. diagn. fr. 
dysentery, 205. 

Iridoplegia, 623. 

Irish ague, see typhus fever, 40. 

Irritable testis a form of neuralgia, 

499- 
Iritis a complication of gonorrhceal 

rheumatism, 339. 
Ischsemia in hysteria, 441. 
Itch, 1285. 
Itch-insects, 1285. 
Itodes ricinus, 1287. 

Jacksonian epilepsy, 458, 461. 
Jaffe's test, 1205. 
Jail-fever, see typhus fever, 40. 
Jaundice, acute infectious, 314. 
Jaundice, catarrhal, 904; emotion a 



cause of, 904; epidemic form, 905; 
inspissated ox-gall in, 906; itch- 
ing of skin in, 905. 

Jaundice in: chobelithiasis, 911; 
from cirrhosis of liver, 890; from 
acute yellow atrophy, 883; from 
cancer of liver, 899; in yellow 
fever, 51. 

Jaw-clonus, 568. 

Jigger, 1288. 

Jumpers, see salt atonic spasm, 482. 

June-cold, 952. 



Katatonia (Kahtbaum), 408. 

Keloid of Addison, 646. 

Keratosis follicularis ( White), 1264. 

Kidney, diseases of, 1189; acute 
Bright' s disease, 1211; amyloid 
or lardaceous disease of, 1231; 
anomalies in form and position, 
1 189; cancer, 1245; chronic inter- 
stitial nephritis, 1225; chronic 
parenchymatous nephritis, 1220; 
congestion of , 11 92; contracted — , 
1220; cystic disease of , 1247; ecchi- 
nococcus of, 1273; gouty, 1225; 
granular, 1225; hydronephrosis, 
1236; large white, 1220, 1221; 
movable, 11 19; perinephric ab- 
scess, 1248; pyelitis, 1233; renal 
calculus, 1239; small white K., 
1 221; syphilis, 283; tuberculosis, 
266; tumors, 1245. 

Kidney, tumors of, diff. diagn. fr. en- 
larged spleen, 1246; fr. en- 
larged gall-bladder, 1246. 

Klebs-Loeffler bacillus, 83, 968. 

Knee-jerk, 568. 

Kreosote-inhalations in consumption, 

253- 
Labyrinthine disease, 630. 
" Lacing " liver, 903. 
Lagophthalmus, 628. 
' ' L,a Grippe, ' ' see epidemic influenza, 

143- 

Lamblia intestinalis, 1264. 

Landry's paralysis, 584; diff. diagn. 



1310 



fr. infantile paralysis, 580; 

fr. multiple neuritis, 616. 
Larvae of flies, diseases caused by 

them, 1289. 
Laryngeal crises, 593; — diphtheria, 

85; — tuberculosis, 259. 
Laryngismus stridulus, 959, 966. 
Laryngitis, acute, 956. 
Laryngitis, cancerous, diff. diagn. fr. 

syphilis, 277. 
Laryngitis, chronic, 961. 
Laryngitis, oedematous, 964; diff. 

diagn. fr. pulmonary oedema, 994; 

fr. retro-pharyngeal abscess, 

727. 
Laryngitis, pseudo-membranous, 968; 

complicating measles, 122; diff. 

diagnosis fr. acute laryngitis, 971; 

— — fr. diphtheria, 88, 971; — 

— fr. false croup, 971; — — fr. 
laryngismus stridulus, 960; — — 

fr. oedema glottidis, 971; fr. 

retro-pharyngeal abscess, 971; ex- 
udate of, 969; Klebs-Losffler ba- 
cillus in, 96S; paroxysms of, 970; 
respiration in, 970; slaked lime in, 
972; steaming in, 972. 

Laryngitis, submucous, 958. 

Laryngitis, syphilitic, 275, 974; diff. 
diagn. fr. lar. tuberculos., 277. 

Laryngitis, tuberculous, 259; diff. 
diagn. fr. lar. syphil., 277. 

Latah, 482. 

Lateral sclerosis, see spastic paraple- 
gia, 585- 

Lavage in: cancer of stomach, 80 r; 
chlorosis, 1156; chronic gastric 
catarrh, 765; dilatation of stom- 
ach, 784; intestinal obstruction, 
859; ulcer of stomach, 792. 

Lead-colic, 66S. 

Lead-palsy, 669. 

Lead-poisoning, 667; anaemia in, 669; 
arterio-sclerosis in, 670; blue line 
along gums in, 669; brain-symp- 
toms, 670; colic in, 663; diagnosis, 
670; forms of localized paralysis, 
669; general palsy in, 669; massage 



in, 671; neuralgia in, 670; treat 
ment, 671; wrist-drop in, 669. 

Leeching in orchitis of mumps, 154. 

" Leichen " tubercle, 213. 

Lepra alopecia, 305. 

Lepra arabum, see leprosy, 302. 

Lepra mutilaus, 305. 

Leprosy, 302; anaesthetic form of, 
305 [anaesthesia in, 305; atrophy 
of the skin in, 305; deformities of, 
305; diff. diagn. fr. Friedreich's 
ataxia, 602; ulceration of, 305]; 
bacillus leprae, 303; clinical forms, 
304; complications, 303; diagno- 
sis, 306; diff. diagn. fr. syphilis, 
306; infectiousness of, 303; lepra - 
tubercle, 303; macular form, 304, 
306; peripheral neuritis in, 304; 
transmission of — by sexual inter- 
course, 303; treatment, 306; tuber- 
cular form, 304 [complications, 
305; description, 304; distribution 
of papules, 304; ulceration of, 
304]- 

Leptomeningitis, 517, 568. 

Leptomeningitis, chronic, 525. 

Leptus iritans, 1287. 

Leucomata in secondary syphilis, 274. 

Leucoderma, 1174. 

Leukaemia, 1164; blood in, 1165,1166, 
1 1 67; bone-marrow in, 1166; caus- 
ation, 1 165; deafness in, 1167; 
diff. between leucocytosis and, 
1 168; lymphatic, 1168; lymphatic 
enlargement in, 1 166; peritonitis 
in, 1 167, spleno-medullary form, 
1 166. 

Lienteric diarrhoea, 812. 

Lightning-pains in ataxia, 590. 

Lipadicuria, 1202. 

Lips, tuberculosis of, 265. 

Lipuria, 1202. 

Lithaemia or irregular gout, 350. 

Lithaemic diathesis, 350, 1202. 

Lithiasis, 350. 

Lithuria, 1202. 

Liver, abscess of, 885. 

Liver, amyloid, 897. 



INDEX. 



1311 



Liver, anaemia of, 915. 

Liver and spleen, enlargement of, in 
rickets, 374. 

Liver, cancer of, S99; diff, diagn. fr. 

cancer of gall bladder, 901 ; 

fr. cancer of omentum, 902; 

fr. cancer of stomach, 901; — — fr. 
dilatation of gall-bladder, 901; — 
— fr. fatty liver, 901; — — fr. 

hydatid tumor of liver, 902 ; 

fr. syphilitic liver, 901 ; fr. 

waxy liver, 901. 

Liver, cirrhosis of, 890. 

Liver, congestion of. 879. 

Liver, cysts of, 902. 

Liver, erectile tumors of, 902. 

Liver, fatty, S96. 

Liver-flukes, 1275. 

Liver, hydatids of, 1272; diff. diagn. 
fr. cancer of liver, 902. 

Liver, hyperaemia of, 915. 

Liver, lardaceous, 897. 

Liver, lymphatic formations of, 902. 

Liver, malformation and malposition, 
903- 

Liver, malignant disease of, 898. 

Liver, movable, 903. 

Liver, syphilis of, 281; diff. diagn. fr. 
cancer of liver, 901. 

Liver, tuberculosis of, 902. 

Liver, waxy, 897; diff. diagn. fr. can- 
cer of liver, 901 . 

Liver, yellow atrophy of, 883. 

Living skeletons, 608. 

Lobar pneumonia, 998. 

Localization, spinal, 563. 

Lock-jaw, see tetanus, 296; also 627. 

Lock-spasms, see tetany, 483. 

Locomotor ataxia, 589; Argyll-Robert- 
son pupil in, 592; cerebral symp- 
toms of, 594; cincture-feeling in, 
591; diagnosis, 595; diff. diagn. fr. 
general paresis, 595; fr. hys- 
teria, 595; fr. multiple neu- 
ritis, 616; fr. peripheral neu- 
ritis, 595; fr. cardiac crises 

of angina pectoris, 595; electricity 
in, 597; fulgurating pains in, 590; 



joint affections in, 594; motor dis- 
turbances in, 591; reflexes in, 592; 
Romberg' s symptom in, 591; sen- 
sory disturbances in, 590; special 
senses in, 592; syphilis as a cause 
of, 589; tabetic crises, 593; treat- 
ment, 596; trophic changes in, 
594; visceral symptoms in, 593. 

Ludwig's angina, 728. 

Luft-hunger" {Kuessmaul) in dia- 
betes, 363. 

Lumbago, 336. 

Lumbar and sacral plexus, lesions of, 
641. 

Lungs, abscess of, . 1019; actinomyco- 
sis, 310; apoplexy, 996; brown 
induration, 994; cancer, 1022; cir- 
rhosis, 1008; congestion of, 993; 
ecchinococcus of, 1273; emphy- 
sema, 1017; gangrene, 1020; 
haemorrhage, 994, 995; iiew 
growths, 1022; oedema, 994; syph- 
ilis, 280; tuberculosis, 225. 

Lung fever, see pneumonia, 998; 

Lupus of the pharynx, 716. 

Luther Bell's disease, see acute peri- 
encephalitis, 398. 

Lymphadenitis, acute, 1040. 

Lymphadenoma, see pseudo-leukas- 
mia, 1 169. 

Lymphangitis in glanders, 307; in 
nodular leprosy, 305; diff. diagn. 
fr. epidemic parotitis, 154. 

Lymphatic form of leukaemia, 1168. 

Lymph, vaccine, 134. 

Lyssa, see rabies, 291. 

Lysophobia, diff. diagn, fr. rabies, 
293- 

Macular leprosy, 304, 306. 

Macular syphilides, 272. 

Magastria, 781. 

Main de griffe in progressive muscular 

atrophy, 608. 
Malarial cachexia, 75; a complicating 

feature in secondary disease, 76; 

characteristics of, 76; enlarged 

spleen in, 76, 77. 



1312 



Malarial fever, 58; diff. diagn. fr. ab- 

cess of liver, 889; fr. yellow 

fever, 53; forms of, 60; hsematozoa 
of Laveran, 59; miasm of, 59. 

Malignant anthrax oedema, 187. 

Malignant fever, see cerebro-spin. 
meningitis, 163. 

Malignant jaundice, see acute yellow 
atrophy, 883. 

Malignant purpuric fever, see cerebro- 
spinal meningitis, 163. 

Malignant scarlet fever, 104; diff. 
diagn. fr. cerebro-spin. meningitis, 
170. 

Malignant pustule, see anthrax, 186, 
187. 

Mallein in treatment of glanders, 309. 

Malta fever, 316; infection of spleen 
by micrococci, 317; mesenteric 
glands, enlargement of, 317. 

Mania, 410; chronic form of, 412; 
filthy habits in, 412; hallucina- 
tions and illusions, 411; moral 
bluntness in, 411; motor delirium 
in, 411; preliminary symptoms of, 
411; satyriasis and nymphomania 
in, 411; speech in, 411; SpitzkcCs 
definition of, 410. 

Mania-a-potu, 663. 

Mania gravis, see acute periencepha- 
litis, 398. 

Marantic thrombi, 545. 

Mastication, spasm of muscles of, 626. 

Marsh-fever, see malarial fever, 58. 

Marshall Hall's spurious hydrocepha- 
lus, 528. 

Mastoid complications of scarlet fever, 
120. 

McBumey's tender point, S45. 

Measles, 120; communication of, 120; 
diagnosis, 123; diff. diagn. fr. 
coryza, 123; — — fr. drug-erup- 
tions, 123; fr. hay -fever, 123; 

fr. rcetheln, 123; — — fr. 

scarlet fever, 107; fr. typhus, 

44; eruption of, 121; forms of, 
122; respiratory complications, 
122; treatment, 123. 



Meat-poisoning, 676. 

Mechanical pulmonary congestion, 
994- 

Median nerve, lesions of, 640. 

Mediastinitis, 1039. 

Mediastinum, abscess of, 1042; emphy- 
sema of, 1043; morbid growths of, 
1040. 

Mediterranean fever, see Malta fever, 
316. 

Medulla oblongata, tumors of, 559. 

Megastoma entericum, 1264. 

Megrim, see migraine, 492. 

Meigs formula for artificial feeding of 
scrofulous infants, 223. 

Melaene, 874. 

Melancholia, 406; conduct in, 407; 
delusions of, 407; nervous symp- 
toms of, 407; sexual power, loss 
of, 408; types of, 408. 

Melano-sarcoma of liver. 899. 

Melanuria, 1205. 

Membranous sore throat, see herpetic 
pharyngitis, 717. 

Meniere's disease, 631. 

Meningeal haemorrhage in birth pal- 
sies, 551, 587. 

Meningitis, acute, 517; meningitis, 
complicating scarlet fever, 105; 
diagnosis, 520; diff. diagn. fr. 

acute periencephalitis, 399; 

fr. cerebral form of fevers, 520; 

fr. pernicious malarial fever, 

74; fr. tubercular meningi- 
tis, 521; subacute form of, 520; 
treatment, 521, 525. 

Meningitis, acute spinal, 568; tuber- 
cular, 522; chronic spinal, 571; 
cerebro-spinal, 163. 

Meningeal fever s see cerebro-spin. 
meningitis, 163. 

Mental diseases, article on, 393; char- 
acter-changes an indication of, 
397; classification of insanities, 
397 [constitutional — , 405; organic 
— , 398; pure — , 406]; delusions 
of the insane, definition and forms 
of, 396; dividing line between 



1313 



sanity and insanity, 393; emo- 
tional disturbances in, 394; hallu- 
cinations, 395; illusions, 395; im- 
pairment of mental equilibrium, 
393; imperative acts, 397; imper- 
ative conceptions, 396; insanity, 
test of, 393; intellectual impair- 
ment, 395; morbid impulse, defi- 
nition of, 397; morbid impulse, 
examples of, 397 [arithromania, 
erotomania, kleptomania, nymph- 
omania, pyromania]; sanity, defi- 
nition of, 393; therapeutics of, 
422; will-force in its relation to 
sanity and mental unsoundness, 
394, 395- 

Mercurial stomatitis, 696. 

Mesentery, affections of, 878. 

Metastatic parotitis, 153. 

Metastatic abscesses, 184. 

Metatarsalgia, 501. 

Meteorism in typhoid fever, 25. 

Micrococcus lanceolatus in pneumo- 
nia, 999. 

Middle cerebral artery, embolism and 
thrombosis of, 543. 

Migraine, 492; reflex irritations in, 
492; treatment, 493. 

Miliarv fever, see sweating sickness, 
316. 

Miliary sclerosis of brain, 553. 

Miliary tuberculosis, 216. 

Milk diet in scarlatinal nephritis, 109, 
119. 

Milk-fever, 318; Way's description, 
3:8. 

Milk, tuberculous infection by, 2r3. 

Mind-blindness, 547. 

Mind-deafness, 548. 

Miner's ansemia, 1279. 

Mitchell's test for diacetic acid, 1206. 

Mitral insufficiency, 1066; clubbed 
fingers in, 1068; comparative fre- 
quency of , 1066; compensation in, 
1067, 1068. 

Mitral stenosis, 1070; compensation 
in, 1071; complications of, 1071; 
funnel-shaped, 1070. 
83 



Moist air in laryngeal diphtheria, 94; 

in epidemic parotitis, 160. 
Monoplegia, facial, 627; in hysteria, 

440; in traumatic neurosis, 488. 
Morbilli, see measles, 120. 
Morbilli hsemorrhagica, 122. 
Morbus coxae senilis, 344. 
Morphiomania, see morphinism, 671. 
Morphinism, 671; withdrawal of the 

drug, 673. 
Morphcea, see circumscribed sclero- 
derma, 646. 
Movable kidney, 1189; dilatation of 

stomach in, 1190; Dietls crises, 

1190; mechanical supports in. 1191. 
Mountain fever, 315. 
Mountain sickness, 315. 
Mountain climate in consumption, 

245- 
Mouth-breathing in chron. tonsillitis, 

736. _ 
Mouth, diseases of, 691. 
Mucous cloud in cystis, 1252. 
Mucous colic, see mucous colitis, 850. 
Mucous colitis, 850; enteralgia in, 851; 

stools of , 851; treatment, 851. 
Mucous patches of secondary syphilis, 

273- 
" Mulberry " calculi, 1240. 
Multilocular cystic kidney, 1247. 
Multiple cysts of kidney in chronic 

fibrous nephritis, 1247. 
Multiple neuritis, 612; diff. diagn. fr. 

infautile paralysis, 5S0; fr. 

locomotor ataxia, 595; — — fr. 

primary myositis, 652. 
Mumps, see epidemic parotitis, 151. 
Muscles, diseases of, 651. 
Muscular atrophy: forms of, 652; 

heredity in, 652; atrophic form, 

654; infantile form, 654; juvenile 

type, 654; peroneal type, 655. 
Muscular atrophy, progressive spinal, 

606. 
Musculo-spiral nerve, lesions of, 640. 
Movable kidney, 11 89. 
Myalgia, see muscular rheumatism, 

335- 



1314 



INDEX. 



Mycosis intestinalis, 186, 187. 

Mycotic stomatitis, 693. 

Myelitis, acute, 573; forms of, 574; 
localization of lesion, 576; motor 
symptoms in, 574; reflexes in, 575; 
sensory symptoms of, 575; treat- 
ment, 5S1, 5S3; trophic disturb- 
ances in, 576. 

Myelitis of the anterior horn, 577; 
electricity in, 5S2; massage in, 
582; contractures, 580; diff. diagn. 
fr. acute polio-myelitis of adults, 
580; — — fr. cerebral palsy of 

children, 580; fr. Landry's 

paralysis, 580; fr. peripheral 

neuritis, 5S0; prognosis, 580; re- 
action of degeneration, 579; re- 
flexes in, 579; treatment, 582; 
trophic changes in, 579. 

Myelitis, transverse, diff. diagn. fr. 
spinal tumor, 606. 

Myosis, 1289. 

Myocarditis, acute, 1099; abscesses in, 
1 100; a complication of rheumatic 
fever, 327. 

Myocarditis, chronic, 1102. 

Myocardium, diseases of, 1098. 

Myoclonia, see paramyoclonus mul- 
tiplex, 657. 

Myodynia, see muscul. rheumatism, 
335- 

Myopathies, the primary, 652. 

Myositis, 651; diff. diagn. fr. trichino- 
sis, 652; fr. multiple neuritis, 

652; suppurative form of, 651. 

Myositis ossificana progressiva, 652. 

Myotonia congenita, see Tkomsen's 
disease, 656. 

Myotonic reaction of Erb, 657. 

Myriachit, 4S2. 

Myxaedema, 1184; differentiation from 
congenital cretinism, 11S4; failure 
of mental and physical vigor, 1 185; 
facial changes in, u 85; increase 
of bulk in, n 84; operative form, 
1. 1 85; thyroid gland feeding in, 
1186; thvroidism, 1186. 



Narcolepsy, 513; a form of hysteria, 

439- 
Nails, in phthisis, 235; in syphilis, 

273- 

Neapolitan fever, see Malta fever, 316. 

Neck, cellulitis of, 72S. 

Necrosis, acute, of bones in rheumatic 
fever, 329. 

Necrosis in tubercle, 215. 

Nephralgia, diff. fr. renal colic, 1242. 

Nephrectomy in movable kidney, 1 191. 

Nephritis, acute, see acute Bright 1 s 
disease, 1211; in scarlet fever, 105, 
119. 

Nephritis, acute desquamative, 121 r. 

Nephritis, chronic interstitial, 1225; 
cardiac hypertrophy in, 1227; 
nervous symptoms in, 1228; pulse 
in, 1227; skin in, 1229; uraemia in, 
1228; urine in, 1227. 

Nephritis, chronic parenchymatous, 
1220; large white kidney, 1221; 
small white (pale granular) kid- 
ney in, 1 221; uraemia in, 1223; 
urine in, 1222. 

Nephritis, chronic, see chronic 
Bright s disease, 1220. 

Nephritis, glomerular, 1211. 

Nephritis of pregnancy, 1215. 

Nephrolithiasis, 1239; coral calculi, 
1239; colic in, 1240; catheteriza- 
tion in, 1243; diagnosis, 1242; diff. 

diagn. fr. appendicitis, 1242; 

fr. hepatic colic, 1242; — — fr. 
intestinal colic, 1242; — — fr. 
nephralgia, 1242; — — fr. stone 
in the bladder, 1242; forms of, 
1240; "infarcts," 1239; morphine 
in, 1243; solvents in, 1244. 

Nephro-phthisis, 266. 

Nephroptosis, see movable kidney, 
1 189. 

Nephrorrhaphy in movable kidney, 
1191. 

"Nerve-storms" (Gowers) in mi- 
graine, 493. 

Nerves, diseases of, cranial — , 619; 
spinal — , 637. 



1315 



Nervous diarrhoea, 443, 810. 

Nervous dyspepsia, 769; diet in, 772; 
forms of, 771; mental condition, 
effect on, 769; nervous symptoms 
of, 771; symptoms chronicity of, 
770; Weir Mitchell treatment in, 
771. 

Nervous irritable weakness, see neu- 
rasthenia, 428. 

Nervous vomiting, 772; similarity to 
gastric crises of tabes dorsalis, 
772. 

Neuralgia, 496; causes of, 496; forms 
of, 497 [cervico-brachial, 498; cer- 
vico-occipital, 498 ; coccydinia, 
499; intercostal, 499; lumbar, 499; 
mastodynia, 499; — of the nerves 
of the feet, 501; phrenic, 498; 
sciatic, 500 ; trigeminal, 497] ; 
treatment, 501. 

Neurasthenia, 428; cerebrasthenia, 429; 
overwork a cause of, 428; rest in, 
431; sexual symptoms of, 429; 
spinal form of, 429; travel in, 431; 
treatment of, 430; types of, 428. 

Neurasthenic state in progressive per- 
nicious anaemia, 1163. 

Neuroses of the stomach, 767; of the 
heart, 1 1 10. 

Neuritis: alcoholic, 614; arsenical. 675; 
endemic, 615; lead-poisoning, 669; 
localized, 611; multiple, 612; post- 
febrile, 615; in typhoid fever, 27, 
615. 

Neuritis, localized, 611. 

Neuritis, multiple, 612; diff. diagn. fr. 

Landry's paralysis, 616; fr. 

locomotor ataxia, 616; forms of 
— , 612; symptoms, 613; treat- 
ment, 616. 

Neuritis, therapeutics of, 617. 

Neuraglioma, 556. 

Neuroma, 618. 

Neuropathic insanity, 415; sexual per- 
versions in, 418. 

Neuroses, occupation, 490. 

New-growths in intestines, 875; in 
lungs, 1022. 



Night-sweats in phthisis, 255. 

Night-blindness, 621. 

Nipple, Paget' s disease of, 1264. 

Nitric acid test for albumin, 1200. 

Nodding spasms, 635. 

Nodes, Heberderi 's 342. 

Nodes of congenital syphilis, 284. 

Nodules, rheumatic, 340. 

Noma, 696; diff. diagn. fr. ulcerative 

stomatitis, 696. 
Nose, bleeding from, see epistaxis, 

955- 
NothnageVs vaso-motor angina, 1122. 
Nummular sputa in phthisis, 231. 
Nut-meg liver, see congestion of liver, 

878. 
Nyctalopia, 621. 
Nystagmus, 626; in Friedreich's 

ataxia, 600. 

Obesity, 685; diet in, 685. 

Obliterative endocarditis, 1102; — 
phlebitis, 1146. 

Obstipation, see intestinal obstruction, 
852. 

Obstruction of bowels, 852; of gall- 
bladder, 914. 

Obturator nerve, 641. 

Occupation neuroses, 490. 

Ocular palsies, 625. 

Ocular muscles, spasm of, 626. 

CEJdema: in anaemia, 1154; angio- 
neurotic, 644; brain, 529; Bright' 's 
disease, 12 14; collateral of lungs, 
994; febrile purpuric, 386; heredi- 
tary, 644; malignant pustule, 187; 
neonatorum, 647; valvular disease 
of heart, 108 r. 

OBdematous laryngitis, 964. 

Oertel's method in obesity, 686. 

CEsophagismus, 749. 

Oesophagitis, 740; cicatricial contract- 
ures in, 741; dysphagia in, 741; 
symptoms, 740; treatment, 741. 

Q^sophagospasmus, 749. 

Oesophagus, cancer of, 747; dilatation 
of, 745; diverticula of, 745; neu- 
roses of, 749; paralysis of, 753; 



1316 



INDEX. 



rupture of, 746; spasm of, 750; 

stricture of, 742; syphilis of, 282; 

tuberculosis, 265. 
Oidium albicans, 693. 
Olfactory nerve, lesions of, 619. 
Oligocythemia in chlorosis, 1157; in 

progressive pernicious anaemia, 

1163. 
Olive oil, treatment of gall-stones, 913. 
Omentum, cancer of, diff. diagn. fr. 

cancer of liver, 902. 
Omodynia, 336. 
Ophthalmoplegia, 625. 
Optic nerve, lesions of, 620; atrophy 

of, 622; chiasm and tract, 622; 

papillitis (optic neuritis), 621; 

retina, affections of, 620. 
Optic neuritis, 621. 

Orchitis in mumps, 153; in tuberculo- 
sis, 267. 
Osteitis deformans of Paget, diff. 

diagn. fr. acromegaly, 646. 
Osteo-arthropathic pneumique 

{Marie), 646. 
Osteo-myelitis, acute, of femur and 

tibia, 329. 
Osteophytes in rheumatic arthritis, 

342. 
Otitis media in: measles, 122; scarlet 

fever, 106; small-pox, 133. 
Over-exertion, action upon enfeebled 

heart, 1060, 1067, 1080, 1084, 1085, 

1096. 
Oxalate of lime calculus, 1240. 
Oxaluria, 1203. 
Oxygen inhalations in diabetic coma, 

367. 
Oxyuris vermicularis, 1277. 
Ozaena, 949. 

Pachymeningitis, 516. 
Pachymeningitis cervicalis hyper- 

trophica {Charcot), 571. 
Pachymeningitis, see also acute spinal 

meningitis, 56S. 
Paget's disease of nipple, 1264. 
Painter's colic, 668. 
Palate in diphtheritic paralysis, 87. 



Palpable kidney, 11 89. 

Palpitation of heart, 1110, 11 13. 

Palsies, cerebral, of children, 549. 

Palsy, lead, 669 

Paludal fever, see malaria, 58. 

Pancreas, disease of, 917. 

Pancreas, cancer, 921; diff. diagn. fr. 

cancer of pylorus, 922; fr. 

cancer of transverse colon, 922. 
Pancreas, calculi, 923; cysts of, 922; 

haemorrhage into, 917. 
Pancreatic disease, relation to diabetes, 

359- 

Pancreatitis, acute, 918; gangrenous 
form, 919; haemorrhagic form, 
918; suppurative form, 919. 

Pancreatitis, acute haemorrhagic diff. 
diagn. fr. intestinal obstruction, 
858. 

Pancreatitis, chronic, 920. 

Pandemic chorea, 481. 

Papillitis, 621. 

Paresthesia in locomotor ataxia, 591 ; 
in neuritis, 612, 613. 

Paragensis, 633. 

Paralysis agitans, 485; attitude and 
gait, 486; diagnosis, 487; diff. 
diagn. fr. senile tremors, 487; 
facial expression, 486; festination 
in, 486; treatment, 487; tremors a 
sign of, 485. 

Paralysis of: bladder in myelitis, 575; 
brachial plexus, 639; circumflex 
nerve, 639; crossed par., 535; dia- 
phragm, 637; facial nerve, 627; 
fifth nerve, 626; fourth nerve, 624; 
hypoglossal, 636; labia-glosso- 
laryngeal, 609; laryngeal abduct- 
ors, 633; laryngeal adductors, 634; 
long thoracic nerve, 639; median 
nerve, 640; musculo-spiral, 640; 
oculo motor nerves, 623, 624, 625; 
olfactory, 619; radial, 640; of 
rectum in myelitis, 575; sixth 
nerve, 624; spinal accessory, 635; 
third nerve, 623; ulnar nerve, 
640; vocal cords, 633. 

Paralysis: acute ascending, 584; acute 



INDEX. 



1317 



spinal of adults, 577; acute spinal 
of infants, 577; agitans, 485; alco- 
holic, 614; BelVs, 627; bulbar, 
609; chronic progressive, 609 
Cruveilhier 's ; 607; divers', 489 
Duchenne's, 606; general, 400 
infantile, 549; labia-glosso-laryn- 
geal, 609; Landry's, 584; lateral 
sclerosis, 585; head, 669; locomo- 
tor ataxia, 589; meningitis, 524; 
myelitis, 603. 

Paralysis after diphtheria, 87, 88, 95; 
after epilepsy, 459; after typhoid 
fever, 27; after typhus fever, 43. 

Paralysis of the insane, see chronic 
periencephalitis, 400. 

Paramyoclonus multiplex, 657; diff. 
diagn. fr. St. Vitus's dance, 477. 

Paranoia, 418; acute mania in, 420; 
dementia the termination of, 418; 
essentials of, 418; hallucinations 
of, 418, 420; of childhood, 419. 

Paraplegia cerebralis spastica (Heine), 
587. _ 

Paraplegia alcoholic, 614; ataxic, 588; 
hereditary, 587; hysterical, 440; 
epastic, 587; syphilitic, 586; from 
tumor of cord, 606. 

Parasites, animal, diseases due to, 1287. 

Parenchymatous nephritis, 1220. 

Paretic dementia, see periencepha- 
litis, 400. 

Parkinson' 's disease, see paralysis 
agitans, 485. 

Parosmia, 620. 

Parotitis, epidemic, 151; symptomatic, 
153- 

Pasteur's treatment of rabies, 295. 

Patellar tendon reflex, see knee-jerk, 
56S. 

Pediculi, 1287. 

Pediculosis, 1287. 

Peliosus rheumatica, see purpura rheu- 
matica, 386. 

Pelvis of kidney, see pyelitis, 1233. 

Pentastoma, 1286. 

Peptic ulcer, see simple ulcer of the 
stomach, 785. 



Peptonuria, see albuminuria, 1197. 
Perforation of bowel in typhoid fever, 

25- 

Pericarditis: plastic, 1047; chronic ad- 
hesive, 1055; chronic tuberculous, 
1055; hcemorrhagic, 1049; puru- 
lent, 1049; sero fibrinous, 1049. 

Pericarditis: aphonia in, 1050; de- 
lirium in, 1050; dysphagia in, 
1050; epilepsy in, 1050. 

Pericarditis in chorea, 476; gout, 350; 
rheumatism, 327; pneumonia, 
1002; scarlet fever, 105. 

Pericarditis, diff. diagn. fr. dilatation 

of heart, 1052; fr. pleural 

effusion, 1052. 

Pericardium, diseases of, 1047. 

Periencephalitis, acute, 398; anaes- 
thesia in, 399; delirium in, 399; 
diagnosis, 399; diff. diagn. fr. 
acute meningitis, 399; — — fr. 

pneumonia, 399; fr. typhoid 

fever, 399; fr. uraemic con- 
vulsions, 400; insomnia in, 399; 
skin-symptoms of, 399; treatment, 
400. 

Periencephalitis, chronic, 400; apo- 
plectiform attacks in, 403; delu- 
sions of grandeur in, 402; diag- 
nosis, 404; diff. diagn. fr. cerebral 
syphilis, 404; — — fr. locomotor 
ataxia, 595; epileptiform convul- 
sions in, 403; gait in, 403; hypo- 
chondriasis in, 402; motor dis- 
turbances of, 403; paralysis of, 
403; periodic forms of, 402; prog- 
nosis, 404; sensibility in, 403; 
speech in, 403; an early tardiness 
symptom of, 402; temperature in, 
403; treatment, 404. 

Peri-encephalo-meningitis, see chronic 
periencephalitis, 400. 

Perihepatitis, 881. 

Perinephric abscess, 1248; diff. fr. 
pyelitis, 1235. 

Periodical insanity, 402, 421. 

Peripheral neuritis, see multiple — , 
612. 



1318 



Periphlebitis, 1146. 

Peristaltic unrest (Kuessmaul), 772; 
in hysteria, 443. 

Peritonaeum, cancer of, 937. 

Peritonaeum, tuberculosis of, 932. 

Peritonitis, acute, 924; abdominal dis- 
tension in, 926; collapse in, 927; 
diff. diagn. fr. acute entero-colitis, 

929; fr. acute gastritis, 929; 

fr. cystitis with distension of 

bladder, 930; — — fr. catarrhal 

enteritis, 818; fr. hysterical 

peritonitis, 930; — — fr. intesti- 
nal obstruction, 929; — — fr. 
puerperal metritis, 929; forms of, 
928; gastro-intestinal symptoms 
of, 927; in appendicitis, 844, 846; 
lavage in, 931; opium in, 930; 
pain in, 926; perforation a cause 
of, 925, 928; septic infection a 
cause of, 925; siphonage in, 930; 
vomiting in, 926. 

Peritonitis, chronic, 931; diff. diagn. 
fr. ascites, 934; forms of, 932; 
tubercular, 932. 

Peritonitis deformans, 932. 

Peritonsillar abscess, see phlegmonous 
pharyngitis, 72 r. 

Peritonsillitis, see phlegmonous phar- 
yngitis, 721. 

Perityphlitis, see appendicitis, 842. 

"Pertes" of Lcennec, 991. 

Pernicious anaemia, 1161; blood in, 
1161, 1163; bone-marrow treat- 
ment of, 1 164; diff. fr. chlorosis, 
r 163; hsemoblastic red marrow in, 
1 162; haemorrhagic effusions in, 
1 163; neurasthenic condition in, 
1163; oligocythaemia in. 1163; ! 
pallor of bodily surface in, 1161; 
urine in, 1162; venous hum in, 
1 162; treatment, 1164. 

Pernicious malarial fever, 72; diagno- 
sis, 73; diff. diagn. fr. cerebro- 

spinal meningitis, 170; fr. 

cholera, 74; fr. meningitis, 

74; fr. pyaemia, 74; fr. 

typhoid fever, 74; fr. ulcera- 



tive endocarditis, 74; — — fr. 
uraemia, 74; of tropics, 73; qui- 
nine in, 74, 75; stimulants in, 75; 
treatment, 74. 

Peroneal type of muscular atrophy, 
655. 

Pertussis, see whooping-cough, 156. 

Petechial fever, see cerebro-spin. men- 
ingitis, 163. 

Petit mal, 455. 

Pettenkofer' s sub-soil theory applied 
to Asiatic cholera, 190; to typhoid 
fever, 20. 

Phantom tumors in hysteria, 440. 

Pharyngitis, acute catarrhal, 705; acute 
infectious, 724: chronic catarrhal, 
706; erysipelatous, 724; gangre- 
nous, 725; sicca, 710. 

Pharyngitis, follicular, 708; follicular 
changes, 709; haemorrhage in, 
709; treatment, 711; voice in, 710. 

Pharyngitis, herpetic, 717; diff. diag- 
nosis fr. diphtheria, 719. 

Pharyngitis, phlegmonous, 721; dysp- 
noea, surgical relief of, 723; 
evacuation of abscess in, 722; 
oedema in, 722; treatment, 722. 

Pharynx, ulceration of, 7r6. 

Phimosis a possible cause of hydrone- 
phrosis, 1239. 

Phlebectasis, 1148. 

Phlebitis, 1145: — suppurativa, 1146. 

Phlegmasia alba dolens, 1145. 

Phlebolites, 1146. 

Phlegmonous stomatitis, 695. 

Phosphates, alkaline, 1203; earth}-, 
1203; triple, 1204. 

Phosphatic calculi, 1240. 

Phosphaturia, 1203. 

Phosphorus poisoning, resemblance to 
yellow atrophy, 885. 

Phrenic nerve, affections of, 637. 

Phrenitis, see acute periencephalitis, 
398. 

Phthisis, pulmonary, see pulmonary 
tuberculosis, 225. 

Phthisis, chronic ulcerative, 228; 



1319 



chronic fibroid, 238; Florida, see 
acute pneumonic phthisis, 225. 

Physiological albuminuria, 1197. 

Picric acid test for albumin, 1200. 

"Pigeon-breast" in rickets, 375; in 
mouth-breathers, 738. 

Pigmentation of skin in: Addison's 
disease, 1174; Basedow's disease, 
1182; phthiriasis, 1287. 

Pin-worms, 1277. 

"Pitting" in small-pox, prevention 
of, 137- 

Plaques jaunes, 542. 

Pleura, diseases of, 1023 

Pleura, echinococcus of, 1273; tuber- 
culosis of, 1032, 1034. 

Pleural effusion: diff. diagn. fr. effu- 
sion of pericarditis, 1052; com- 
pression of lungs in, 1025; haem- 
orrhagic, 1032; position of heart 
in, 1025; purulent, 1029; serous, 
1025; sudden death from, 1028. 

Pleural membrane, calcification of, 
1034. 

Pleurisy, acute, 1023; complicating 
pneumonia, 1002; complicating 
scarlet fever, 105; diff. diagn. fr. 

intercostal neuralgia, 1033; 

fr. pneumonia, 1033; — — ■ fr. 
pleurodynia, 1033 dry, 1024; 
hsemorrhagic, 1632; purulent, 
1029 [following sero-fibrinous, 
1030; perforation in, 1031; preva- 
lence among children, 1029] ; sero- 
fibrinous, 1024; with effusion, 
1024. 

Pleurisy, chronic, 1033; diff. diagn. 
fr. pulmonary tuberculosis, 239. 

Pleurisy, diaphragmatic, 1032; en- 
cysted, 1032; haemorrhagic, 1032; 
interlobar, 1033; pulsating, 1031; 
purulent, 1029; sero-fibrinous, 
1024; tuberculous, 1032. 

Pleuritis humida, 1024; sicca, 1024. 

Pleurodynia, 336; diff. fr. pain of acute 
pleurisy, 1033. 

Plexiform neuroma, 619. 

Plica polonica, 1287. 



Plumbism, see lead-poisoning, 667. 

Pneumogastric nerve, affections of, 
663. 

Pneumonia, 998; breathing in, 1002; 
bronchitis in, 1003; cerebral symp- 
toms of, 1003; clinical varieties, 
1004; complicating epidemic in- 
fluenza, 146; complicating gland- 
ers, 307; complicating scarlet 
fever, .106; complications, 1003; 
cough in, IC02; diagnosis, 1006; 
diff. diagn. fr. acute pleurisy, 
:o 33; fr- acute periencepha- 
litis, 399; fr. broncho-pneu- 
monia, 1014; fever in, 1001; heart 
symptoms of, 1002; in diabetics, 
1005; in drunkards, 1005; in in- 
fants, 1004; in the old, 1005; 
micrococcus lanceolatus, 999; pain 
in, 1002; pericarditis in, 1003; 
pleurisy in, 1003; stages of, 999; 
treatment, 1006. 

Pneumonia, acute croupous, see pul- 
monary tuberculosis, 240. 

Pneumonia, aspiration, 1011. 

Pneumonia, catarrhal, see broncho- 
pneumonia, 1010. 

Pneumonia, chronic interstitial, 1008; 
bronchiectasis in, 1009; pneumo- 
nokoniosis, a form of, 1010. 

Pneumonia, deglutition, ion. 

Pneumonia, lobular, see broncho- 
pneumonia, 1010. 

Pneumonitis, see pneumonia, 988. 

Pneumonokoniosis, 1010. 

Pneumopericardium, 1057. 

Pneumorrhagia, 994. 

Pneumothorax, 1037; diff. diagn. fr. 

diaphragmatic hernia, 1038; 

fr. emphysema, 1038. 

Pneumotoxin, 999. 

Pneumo-typhus, 23. 

Podagra, 346. 

Poikilocytosis, 1157, 1163. 

Polio-encephalitis superior acuta, 625. 

Polio-myelitis anterior, 577. 

Pollen-catarrh, see hay -fever, 952. 

Polydipsia, see diabetes insipidus, 369. 



1320 



Polyneuritis, see multiple neuritis, 
612. 

Polypanarthritis, see rheumatic arth- 
ritis, 340. 

Polysarcia, see obesity, 6S5. 

Polyuria, see diab. insip., 369. 

Pons, tumors of, 559. 

Popliteal nerve, affections of, 641. 

Porencephalus, 550. 

Portal vein, suppurative inflammation 
of, 9 r6; thrombosis, 916. 

Post-diphtheritic paralysis, 95. 

Post-febrile neuritis, 615. 

Post-hemiplegie movements [Ham- 
mond), 550. 

Post-mortem wart, 213. 

Posterior spinal sclerosis, see loco- 
motor ataxia, 589. 

Pott's disease, consult compression 
myelitis, 602. 

Priapism in leukaemia, 1167. 

Primary combined sclerosis of spine, 
538. 

Primary muscular dystrophy, see pro- 
gressive muscular atrophy, 652. 

Primary myopathy, see progressive 
muscular atrophy, 652. 

Professional spasms, see occupation 
neuroses, 490. 

Progressive chronic articular rheuma- 
tism, 340. 

Progressive muscular atrophy, 652; 
atrophic form, 654; constitutional 
bias in, 652; contractures in, 653; 
diagnosis, 655; facies myopathique 
in, 655; infantile type of Du- 
chenne, 654; juvenile form of Erb, 
654; peroneal type, 655; posture 
i". 653; pseudo - hypertrophic 
forms of, 653; treatment, 656. 
Progressive muscular atrophy, see 
also progressive spinal muscular 
atrophy, 606. 
Progressive pernicious ansemia, see 

pernicious anaemia, 1161. 
Progressive septicaemia, 183. 
Progressive spinal muscular atrophy, 
606. 



Prosopalgia, see neuralgia of trige- 
minus, 497. 

Prostate, tuberculosis of, 267. 

Prune-juice expectoration, 1023. 

Pruritus in: diabetes 362; obstructive 
jaundice, 905; pseudo-leukaemia, 
1 171; uraemia, 1209. 

Pseudo-angina pectoris, 11 20. 

Pseudo-hypertrophic muscular paralj'- 
sis, see progr. muscular atrophy, 
652. 

Pseudo-leukaemia, see Hodgkin's dis- 
ease, 1 169. 

Pseudo-membranous djsentery, 203. 

Psorosperms, 1263. 

Psorospermiasis, 1264. 

Ptomaine-poisoning, 676; by fish and 
shell-fish, 678; by milk-products, 
678; by meats, 676; JVelbeck's 
description of cases, 676. 

Ptosis, 623. 

Ptyalism, 704. 

Puberty, barking cough of. 443. 

Pulex irritans, 1289; penetrans, 1288. 

Pulmonary abscess, 1019; apoplexy, 
996; congestion, 993; haemorrhage, 
994; oedema, 994; tuberculosis, 
225. 

Pulmonary artery, aneurism of, 1 142. 

Pulmonary complications in diabetes, 
361; in rheumatic fever, 328. 

Pulmonary insufficiency, 1079. 
; Pulmonary stenosis, 1079. 

Pulmonary tuberculosis and whooping 
cough, 159. 

Pulse, irregular, 11 18; pulsus alter- 
nans, 111S; p. bigeminus, ni8;p. 
dicrotus, 11 18; p. intermittens, 
1 118; delirium cordis, ni9;embry- 
ocardia, 1119; fatal heart rhythm, 
1 1 19; gallop-rhythm, 11 19; water- 
hammer pulse, 1119. 

Pulsus celer in aortic insufficiency 
1073. 

Pulsus paradoxus in pericarditis, 1050. 

Pulsus tardus in arterio-sclerosis, 
1129. 

Pupil, Argyll-Robertson, 623. 



1321 



Purdy on the nature of diabetes, 358. 

Purpura, 385; cachexia a cause of, 
385; forms of, 386 [p. hsemor- 
rhagica, 387; p. rheumatica, 386; 

in children, 387; p. simplex, 

3S6]; hsematidrosis, 385; haemor- 
rhage, treatment of, 387; pete- 
chise, 385; vibices, 385. 

Purpura fulminans, 3S7; p. urticans, 
386; p. variolosa, 132. 

Purpuric oedema, 386. 

Pustule, malignant, 1S6. 

Putrid sore mouth, 695. 

Putrid continued fever, see typhus f., 
40. 

Putrid sore throat, see gangrenous 
pharyngitis, 725. 

Pyaemia, 183; chronic, 184; a cause 
of pulmonary abscess, 1019; diff. 
diagn. fr. malignant endocardit- 
is, 1063; fr. actinomycosis, 

311; — — fr. pernicious malarial 
fever, 74; — — fr. . rheumatism, 

184; fr. typhoid fever, 184; 

micro-organisms of , 183; sweating 
in, 184; treatment, 185. 

Pyelitis, 1233; calculi a frequent 
cause of, 1233; diff. fr perinephric 
abscess, 1235; fever in, 1235; 
ova of parasites a cause of, 1233; 
pyuria in, 1234. 

Pyelonephritis, see pyelitis, 1233. 

Pylephlebitis adhesiva, 916; suppura- 
tiva, 916. 

Pylorus, cancer of, diff. diagn. fr. 
cancer of pancreas, 922. 

Pyonephrosis, 1233. 

Pyo-pneumothorax, 1037. 

Pyuria, 1201. 

Quarantine against Asiatic cholera, 

194; yellow fever, 54. 
Quartan ague, 63. 
Quinine, mode of administering it in 

intermittent fever, 64. 
Quincke's capillary pulse, 1074, 1075. 
Quinsy, see acute tonsillitis, 729. 
Quotidian ague, 63. 



Rabies, 291; communicability of, 291; 
convulsions of, 292; diff. diagn. 
fr. lyssophobia, 293; — — fr. 
tetanus, 293; fear of water in, 292; 
furious stage of, 292; inoculation 
of, 291; paralytic stage, 292; 
Pasteups treatment, 294; psychic 
stage, 291; treatment, 293. 

Rachitis, see rickets, 372. 

Radial paralysis, 640. 

Railway spine, 487. 

Rapid heart, mi. 

Ray-fungus in actenomycosis, 310. 

Raynaud's disease, 642; asphyxia in, 
642; cerebral involvement, 643; 
electricity in, 644; hsemoglobinu- 
ria in, 643; sloughing in, 643; 
syncope in, 642; treatment, 644. 

Reaction of degeneration, 579. 

Recondescenceof fever in typhoid, 24. 

Rectal cancer, diff. diagn. fr. dys- 
entery, 205. 

Recurrent laryngeal nerve, affections 
of, 634. 

Recurring typhus, see relapsing fever, 

45- 

Reflex chorea, 480 

Reflex epilepsy, 452. 

Reflexes. 567. 

Regurgitation, tricuspid, 1077 

Relapsing fever, 45; "bilious typhoid " 
form, 47; causation, 45; complica- 
tions, 47; contagiousness of, 46; 
micro-organisms in blood of, 46; 
symptoms, 46; treatment, 48. 

Relapsing typhus, see relapsing fever, 

45- 

Remittent fever, 69; diff. diagn. fr. 
typhoid fever, 29; duration, 70; 
fever and temperature, 69; nerv- 
ous symptoms of, 70; paroxysms 
of, 70; sequels, 70; treatment, 70. 

Renal calculus, 1239; solvents of, 1244. 

Renal colic, 1240. 

Renal complications in diabetes, 361; 
in diphtheria, 87. 

Renal sclerosis, see chronic interstitial 
nephritis, 1225. 



1322 



Renal tumors, diff. fr. enlarged spleen, 
1246. 

Respiratory system, diseases of, 945. 

Rest-treatment in aneurism, 1139; in 
hysteria, 446; neurasthenia, 431. 

Retina, lesions of, 620. 

Retinal hyperaesthesia, 621. 

Retraction of head in meningitis, 519, 
524- 

Retro-colic spasm, 636. 

Retro-pharyngeal abscess, 726; diff. 
diagn. from membranous croup, 
727; — — fr. oedema of larynx, 
727; fr. mumps, 154; treat- 
ment, 728. 

Rhagades, 284. 

Rheumatic arthritis, 340; articula- 
tions, changes in, 342; atrophy of 
muscles, 342; diagnosis, 344; diff. 
diagn. fr. acute rheumatism, 344; 

fr. gout, 344, 352; fr. 

local arthritis of shoulder-joints, j 
344; electricity in, 345; forms of, 
342; Heberden's nodosities, 342; 
and endocarditis, 1058; mono- 
articular, 344; neurotic origin, 
theory of, 344; rest in, 345; treat- 
ment, 344. 

Rheumatism, chronic articular, 332; 
anatomical changes, 332; baths 
in, 333; climate, 333; diff. diagn. 
fr. gout, 351; treatment, 333. 

Rheumatic fever, 323; age in, 323; 
anaemia in, 326; baths in, 330; ; 
climatic causes, 323; complica- 
tions, 326; diagnosis, 329; diet in, 
330; diff. diagn. fr. acute arthritis 
of infants, 329; — — fr. acute 
necrosis of femur and tibia, 329; 
— — fr. acute osteo-myelitis of 



femur and tibia, 329; — — fr. 
cerebro-spinal meningitis, 170; — 
— fr. dengue fever, So; — — fr. 
gout, 329; — — fr. malignant 
endocarditis, 1063; fr. pyae- 
mia, 184; fr. rheumatic arth- 
ritis, 344; fr. septic arthritis, 

329; fever in, 325, 326, 328; Ful- 



ler's solution in, 330; heart com- 
plications, 327; hyperpyrexia in, 
328; infection in, 324; joint affec- 
tions in, 325; metabolic theory of 
causation, 324; nodules under the 
skin in, 326; subacute form, 326; 
sweating in, 326; treatment, 329; 
urine in, 326. 

Rheumatic gout and arthritis defor- 
mans, 352. 

Rheumatism, gonorrhceal, 338; diag- 
nosis, 340; diff. fr. true rheuma- 
tism, 339; electricity in, 340; forms 
°f> 339; treatment, 340. 

Rheumatism, muscular, 335; aetiology, 
335; baths (Turkish) in, 336; deep 
puncture in lumbago. 337; elec- 
tricity in, 337; forms of, 336; gout 
a cause of, 335; of abdominal 
muscles, diff. diagn. fr. enteralgia, 
869; strapping in pleurodynia, 337; 
treatment, 336. 

Rhinitis, acute catarrhal, see acute 
nasal catarrh, 945 

Rhinitis, atrophic, 949. 

Rhinitis, hypertrophic, 948. 

Rhinitis, periodical hyperaesthetic, see 
hay-fever, 952. 

Rhinitis, syphilitic, 283. 

Rhythmic chorea, 483. 

Rice-water stools in cholera, 192. 

Rickets, 372; aetiology, 372; age in, 
372; baths in, 378; bone-lesions 
in, 374; cod-liver oil in, 379; 
cranio-tabes in, 375; diagnosis, 
377; eclampsia in, 377; Harrison's 
groove a sign of, 375; in the 
newborn, 372; liver and spleen in, 
374; mental condition in, 377; 
pigeon-breast, a sign of, 375; ro- 
sary of, 375; shape of head in, 
375; sweating in, 374; treatment, 
378. 

Rickets, acute, in children, 383. 

Rickets, spastic rigidity of, diff. fr. 
spastic diplegia, 551. 

Rigors in: abscess of brain, 555; ab- 
scess of liver, 888; ague, 61, 69, 



INDEX. 



1323 



72,73; pneumonia, 1000; pyaemia, 
184; pyelitis, 1235; tuberculosis, 
227; typhoid fever, 24. 

Risus sardonicus, 298. 

Rock fever, see Malta fever, 316. 

Roethelu, see rubella, 127. 

Romberg's symptom, 591. 

Root-nerve symptoms in compression 
myelitis, 603. 

Rosary of rickets, 375. 

"Rose," see erysipelas, 176. 

Rose-cold, see hay-fever, 952. 

Roseola of syphilis, 272. 

Round ulcer of stomach, see simple 
ulcer of stomach, 785. 

Rubella, 127; diff. diagn. fr. measles, 
123, 128; — — fr. scarlet fever, 
107; eruption of, 128; treatment, 
128. 

Rubeola notha, 127. 

Rumination of food, 773. 

Rupture of the heart, 1108. 

Russian catarrh, see epidemic influ- 
enza, 143. 

Sacral plexus, lesions of, 64.1. 

Saccharine diabetes, see diab. mell., 
357- 

Salaam convulsions in hysteria, 441. 

Saliva, arrest of secretion, 704; hy- 
persecretion, 704. 

Salivary glands, diseases of, 704. 

Salivation, see ptyalism, 704. 

Saltatoric spasm, 482. 

Sand-flea, 1288. 

Sapraernia, a form of septicaemia, 182. 

Sarcoma of: brain, 556; kidney, 1245; 
liver, 899; lung, 1022; mediasti- 
num, 1042. 

Sarcoptes hominis, 1285. 

Saturnism, see lead-poisoning, 667. 

Sausage-poisoning, 676. 

Scapulodynia, 336. 

Scarlet fever, roo; affection of serous 
membranes in, 105; ataxic or ful- 
minant, 104; complications, 105; 
conveyance of, 100; desquama- 
tion, 103; diagnosis, 106; diff. 



diagn. fr. acute exfoliating der- 
matitis, 106; fr. diphtheria, 

89, 106; fr. measles, 107; — 

— fr. rcetheln, 107; fr. septi- 
caemia and pyaemia, 107; ear- 
affections in, 106, 117, 120; essen- 
tial poison of, roo, ior; fever, 
102; hemorrhagic form of, 104; 
hyperaemia of skin in, 102; ma- 
lignant, 104; nephritis in, 105, 
119; prophylaxis of, 107; rash of, 
ior, 102; sequels of, 105; sore 
throat, treatment of, 113; straw- 
beny tongue of, 102; throat- 
symptoms of, 103, 113; treatment, 
107. 

Scarlatinal diphtheria, 103; nephritis, 
105, 119. 

ScKcenleiri 1 s disease, see purp. rheum., 
386. 

Sciatica, 500. 

Sciatic nerve, affections of, 500, 641. 

Scirrhous disease of stomach, 794; of 
pancreas, 921. 

Sclerema neonatorum, 647. 

Sclerodactylia, 647. 

Scleroderma, 647. 

Scolices of echinococcus, 1271. 

Scorbutus, see scurvy, 380. 

Scrivener's palsy, 490. 

Scrofulosis, 222. 

Scrofulous kidney, 1234. 

Scurvy, 380; blood in, 382; compli- 
cations, 382; diagnosis, 383; diff. 
diagn. fr. acute rickets, 383; diet 
in, 383; gums in, 381, 384; haem- 
orrhage in, 382; infantile type. 
383; lemon-juice in, 381, 384; 
necrosis of soft tissues in, 381; 
treatment, 383. 

Sea-bathing in scrofulosis, 223. 

Sea-voyages for consumptives, 245. 

Secondary fever of small-pox, 130. 

Secondary parotitis, 153. 

Secondary spastic paralysis, 587. 

Senile tremors, diff. from tremors of 
paralysis agitans, 487. 



1324- 



Sensation, loss of painful, in syringo- 
myelia, 601. 
Sensation, retardation of, in ataxia, 

59T- 

Septicaemia, 1S1; cliff, diagn. fr. scar- 
let fever, 107; fr. tuberculo- 
sis, 184; micro-organisms of, 182; 
relation to pyaemia, 182. 

Septic processes a cause of malignant 
endocarditis, 106c. 

Septico-pysetnia, 185. 

Serratus palsy, 639. 

Serum-albuminuria, 1197. 

Serum-treatment of glanders, 309; of 
tetanus, 300. 

Shaking palsy, 485. 

Shell-fish, poisoning by, 678. 

Ship-fever, see typhus, 40. 

Shock in traumatic neurosis, 487. 

Sick headache, see migraine, 492. 

Siderosis, 1010. 

Simple catarrh, diff. fr. epidemic in- 
fluenza, 148. 

Singultus, 638. 

Sixth nerve, affections of, 624. 

Skin,, dryness of, in acute nephritis, 
1 2 15; itching of, in uraemia, 1209. 

Skoda' s resonance, 1028. 

Skull of: congenital syphilis, 284; hy- 
drocephalus, 561; rickets, 375. 

Sleep, 507; definitions of sleep, stupor, 
coma (H. C. Wood), 507; hypna- 
gogic state. 508; insomnia, 509; 
narcolepsy, 513; somnambulism, 
514; somnambulic dreams, 514; 
somnambulic lethargy, 514; som- 
nambulic life, 515. 

Slow pulse, 11 19. 

Small-pox, see variola, 129. 

Small-pox, malignant, 170. 

Smell, affections of sense of, 619. 

Snuffles, 2S3. 

Softening of the brain, 402. 

Solvent treatment of renal calculi, 
1244. 

Somnambulism, 514. 

Sour, see parasitic stomatitis, 693. 



Sore throat, see acute catairhal phar- 
yngitis, 705. 

Spasmodic wry-neck, 635. 

Spastic diplegia, 551; diff. diagn. fr. 
spastic rigidity of rickets, 551. 

Spastic paraplegia, 585. 

Spastic paraplegia of infants, 587. 

Spastic spinal paralysis, see spastic 
paraplegia, 5S5. 

Speech, see aphasia, 546. 

Speech in: adenoid vegetations, 737; 
bulbar paralysis, 609, 610; general 
paralysis, 403; hereditary ataxia, 
600; insular sclerosis, 553; paraly- 
sis agitans, 486. 

Spinal accessorv nerve, paralysis of, 
635. 

Spinal apoplexy, 572. 

Spinal concussion, effects of, 487. 

Spinal cord: acute leptomeningitis, 
568; anaemia, 572; chronic lepto- 
meningitis, 571; compression of, 
602; congestion of, 572; embolism 
and thrombosis of, 572; endarteri- 
tis of, 572; haemorrhage into, 572; 
myelitis, 573; sclerosis, 585, 607; 
syphilis, 280; tuberculosis, 268; 
tumors, 605. 

Spinal cord, focal lesions of, 563; 
above lumbar enlargement, 565; 
at lumbar enlargement, 565; in 
mid-dorsal region, 564; in upper 
cervical region, 563; hemipara- 
plegia, 566; of cervical enlarge- 
ment, 564; of lateral half of cord, 
565; spinal hemiplegia, 566. 

Spinal curvature in rickets, 375. 

Spinal epilepsy of Brown-Sequard, 
587. 

Spinal: hemiparaplegia, 566; hemi- 
plegia, 566; irritation, 428, 487; 
meningitis, 56S, 571; muscular 
atrophy, 606; nerves, affections 
of, 637; neurasthenia, 4S7; paraly- 
s ' s > 577; syphilis, 280. 

Spirals, Curschmann's, 991. 

Spirillum of Obermeyer, 46. 



1325 



Spirochetes in blood of relapsing fever, 
46. 

Spleen, enlargement in rickets, 374. 

Spleen in: ague, 6o, 69, 76; anthrax, 
188; Hodg kin's disease, 11 70; 
leukaemia, 11 65; typhus, 41. 

Spleen, rupture of, in malaria, 60. 

Splenic enlargement in pseudo-leukae- 
mia, 1 170. 

Spleno-medullary form of leuksemia, 
1166. 

Spondylitis deformans, 344. 

Sporadic cholera, see, cholera morbus, 
813. 

Sporozoa, 1263. 

Spotted fever, see cerebro-spin. men- 
ingitis, 163 (see also page 40). 

Spurious hydrophobia, 437. 

Sputa in: acute bronchitis, 977; bron- 
chial asthma, 991; bronchiectasis, 
989; cancer of lung, 1022; chronic 
bronchitis, 982; fibrinous bron- 
chitis, 987; pneumonia, 1001, 1002, 
1009; pulmonary gangrene, 1021; 
pulmonary phthisis, 226, 229, 231, 
232; putrid bronchitis, 983. 

St. Anthony's fire, see erysipelas, 176. 

Status epilepticus, 455. 

Stenocardia, 11 20. 

Stenosis of aortic orifice, 1076; of 
mitral orifice, 1070; of pulmonary, 
1079; of tricuspid, 1078. 

Stenosis of gall-duct, 915. 

Steppage gait, 616. 

Stercoraceous vomiting, 855. 

Sternalgia, 11 20. 

Stigmata-bleeding points, 386. 

Stigmata in hysteria, 442. 

Stomach, atrophy of, 809; relation to 
cancer, 809; — to pernicious an- 
aemia, 809. 

Stomach, cancer of, 794; age in, 794; 
anaemia in, 798; complications, 
799; diagnosis, 799; diff. diagn. 
fr. chronic gastric catarrh, 799, 
800; — — fr. gastric ulcer, 799, 
800; fever in, 799; forms of, 795; 
haemorrhage in, 797; heredity in, 



794; hydrochloric acid, absence of 
in gastric juice, 797; involvement 
of distant organs, 796; lavage in, 
801; location in, 794; pain, 797; 
perforation in, 795; treatment, 
801; tumors an important sign of, 
798; ulceration a feature of, 795; 
vomiting in, 797. 

Stomach, dilatation of, 781 ; cicatricial 
tissue a cause of, 781; diagnosis, 
784; electricity in, 784; lavage in, 
784; massage in, 785; mechanical 
causes of, 781; muscular atony of, 
781; physical signs, 783; tetany 
in, 783; vomiting in, 782. 

Stomach, simple ulcer of, 785; charac- 
ter of ulcer, 786; cicatrization in 
— , effects of, 787; course of, 789; 
diagnosis, 790; diff. diagn. fr. 

gall-stone colic, 790; fr. gas- 

tralgia, 790; fr. haemoptysis, 

790; feeding in, 791; haemorrhage 
in, 788; necrosis of tissue in, 787; 
pains in, 788; perforation in, 787, 
789; self-digestion in, 786; tender- 
ness to touch, 789; treatment, 791; 
Virchow on the cause of, 786; 
vomiting in, 789. 

Stomach: abscess of wall, 809; al- 
buminoid disease, 809; cirrhosis, 
807; fibroid induration (cirrho- 
sis), 807; haemorrhage, 802; lard- 
aceous disease, 809; neuroses, 767 
perforation, 810; rupture, 810 
stenosis of cardiac orifice, 806: 
stenosis of pyloric orifice, 807 
tubercle of, 809; waxy disease, 
809. 

Stomatitis, 691; aphthous, 692; catar- 
rhal, 691; gangrenous, 691; mer- 
curial, 696; parasitic, 693 [diff. fr. 
aphthous, 694]; ulcerative, 695 
[diff. fr. aphthous, 696; — fr. 
noma, 696; — fr. sore mouth of 
nursing women, 696]; treatment, 
698. 

Strangulation and intussusception, 
852; cause of intestinal obstruc- 



1326 



tion, 852; diagnosis, S5S; diff. fr. 

appendicitis, 847. 
Strawberry tongue in scarlet fever, 

102. 
Stricture, intestinal, 853; a cause of 

obstruction, 853. 
Stricture, oesophageal, 742. 
Stricture of pylorus, 781, 795, 807. 
Strongylus, 1280. 
Struma, 220. 
Strychnine-poisoning, diff. fr. tetanus, 

299. 
St. Vitus's dance, see acute chorea, 

472. 
Sudden death in valvular disease of 

the heart, 1074. 
Suffocative catarrh, 1013. 
Sugar in urine, tests for, 364. 
' ' Suggestion ' ' in treatment of hys- 
teria, 448. 
Sulphuric acid, dilute, a preventive of ! 

cholera, 195. 
Sunstroke, 680. 
Suppurative encephalitis, 554; sepsis 

a cause of, 554; trauma in, 554; 

treatment, 556. 
Suppurative nephritis, 1234. 
Suppurative pylephlebitis, 463. 
Suppurative tonsillitis, 731. 
Supra- renal glands in Addison's dis- 
ease, 1 173. 
Supra-renal glands of animals in 

treatment of Addison's disease, 

H75- 

Surgical kidney, see pyelitis, 1233. 
Suspension in compression paraplegia, 

604. 
Swamp fever, see malarial fever, 58. 
Sweating sickness, 316. 
Sydenham's chorea, 472. 
Symmetrical gangrene, 642. 
Syncope, treatment of, 529. 
Synovial rheumatism, see gonorrhceal 

rheumatism, 338. 
Synovitis in scarlet fever, 105. 
Syphilides, 272, 274. 
Syphilis, 269; aetiology, 269; Colles's 

law of transmission, 270; diag- 



nosis, 285; hereditary transmis- 
sion, 269; marriage of syphilitics, 
287; mercurial treatment of, 287; 
micro-organisms of, 269; modes 
of infection, 269; Potass, of iodide 
treatment, 287; stages of develop- 
ment, 269; treatment, 2S6. 

Syphilis, acquired, 270; primary 
stage, 271 [initial sore, 271; lym- 
phatic glands, involvement of, 
271]; secondary, 272 [anaemia, 
272; eye-and-ear symptoms, 274; 
fever, 272;. glandular enlarge 
ments, 273; hair and nails in, 
273; mucous membrane in, 273; 
skin in, 272]; tertiary stage, 274 
[laryngeal involvement, 275 ; 
skin-symptoms, 274]. 

Syphilis of digestive tract, 282; heart 
and blood-vessels, 282; kidney 
and testicles, 283; larynx, 275 
[diff. fr. tuberculosis and cancer, 
277]; pharynx, 717; liver, 281; 
lungs, 280; nervous system, 278 
[cerebral syphilis, 279; spinal 
syphilis, 280]. 

Syphilis in fibrous hepatitis, 891. 

Syphilis, diff. fr. leprosy, 306; fr. pul- 
monary tuberculosis, 240. 

Syphilis of liver, diff. fr. cancer of 
liver, 901. 

Syphilis of rectum, diff. fr. dysentery, 
205. 

Syphilis, relation to locomotor ataxia, 

589 
Syphilitic spastic paralysis {Erb), 

586. 
Syphilitic ulceration of larynx, 717. 
Syringomyelitis, 601; — diff. diagn. fr. 

anaesthetic leprosy^, 602. 

Tabes, diabetic, 362. 

Tabes dorsalis, see locomotor ataxia, 

589- 

Tabes mesenterica, 222. 

Tabetic crises, 593. 

Tache cerebrale in tubercular menin- 
gitis, 524. 



1327 



Tachycardia, mi; in exophthalmic 
goitre, 1180; in valvular disease 
of the heart, 1081. 

Taenia echinococcus, 1270. 

Taenia elliptica, 1266; t. cucumerina, 
1266; t. flavopunctata, 1266; t. 
Madagascariensis, 1266; t. nana, 
1266. 

Taenia s'aginata, 1266. 

Taenia solium, 1265. 

Tape-worm, 1265; treatment of, 1268. 

Taste, disturbances of, 633. 
eeth, looseness of, in scurvy, 381; 
Hutchinson 's in congenital syph- 
ilis, 284. 

Temperature-sense, loss of in syringo- 
myelia, 601. 

Tender points in hysteria, 441; in 
neuralgia, 497. 

Tendon reflexes, 567. 

Terminal dementia, 414. 

Tertian ague, 63. 

Testicles, orchitis in mumps, 153; 
syphilis of, 283; tuberculosis of, 
267. 

Tetanus, 296; bacillus of, 297; con- 
vulsions of, 297; diagnosis, 299; 
diff. diagn. fr. hydrophobia, 293, 

299; fr. hysteria, 299; 

fr. strychnine-poisoning, 299; in 
the new-born, 296; mortality, 299; 
serum-treatment, 300; symptoms, 
297; transmission by inoculation, 
297; treatment, 299. 

Tetany, 483. 

Tete caree in rickets, 375. 

Thermic fever, see heat-exhaustion, 
680. 

Thermic sense, loss of, 441, 601. 

Third nerve, lesions of, 623. 

Thirst in diabetes, 361; in cholera, 
192. 

Thoracic aorta, aneurism of, 1134; 
asthma in, 1136; diff. fr. solid 
tumors, 1138; electrolysis in, 1140; 
of ascending portion, 1134; of de- 
scending portion, 1136; of trans- 
verse portion, 1135; pain in, 1136; 



perforation into superior vena 
cava, 1 135; pressure symptoms, 
1134; Valsalva's method in, 1139. 

Thomsen' s disease, 656. 

Thoracic nerve, long, affections of, 639. 

Thorax, deformity in mouth-breathers, 
738; in rickets, 375. 

Thread-worms, 1277. 

"Thrill" in aortic aneurism, 1137; in 
mitral stenosis, 1071. 

Thrombi, marantic, 545. 

Thrombosis of cerebral sinuses, 545; 
in valvular disease, 1083. 

Thrombosis of longitudinal sinuses in 
chlorosis, 1157. 

Thrush, 693. 

Thymic asthma, 966. 

Thymus gland, affections of, 1043. 

Thyroid extract, administration of, 
1178, 1183, 1186. 

Thyroid gland, diseases of, 1 176. 

Thyroidism, 1186. 

Tic convulsif, 481. 

Tic douloureux, 497. 

Ticks, 1287. 

Tinnitus aurium, 630. 

Tongue, in bulbar paralysis, 619; in- 
flammation of, 701; ulcer of, 703; 
ulcer of fraenum in whooping 
cough, 158. 

Tonsillitis, 729; causation, 729; diag- 
nosis, 731; diff. diagn. fr. diph- 
theria, 731; fr. scarlatinal 

angina, 732; forms of , 730; oedema 
in, 732; predisposition to, 729; 
scarification in, 733; spontaneous 
evacuation of abscess, 731; strum- 
ous diathesis in, 729; surgical re- 
lief of, 733; treatment, 733. 

Tonsillitis, chronic, 734; adenoid 
growths in, 736; deafness in, 737; 
foul breath in, 737; mouth-breath- 
ing in, 736; operative treatment, 
738; relation to simple endo- 
carditis, 1058; thorax, appearance 
of, in, 737. 

Tonsils, abscess of, 731, 733; calculi, 



1328 



INDEX. 



737; enlargement of, 736; tuber- 
culosis. 259, 265. 

Tophi in gout, 347, 348. 

Torticollis, 336, 635. 

Toxic gastritis, 756. 

Toxsemic insanity, 406. 

Tracheal tugging (Oliver), 1138. 

Trance in hysteria, 439. 

Traumatic neurosis, 487. 

Trematodes, diseases caused by, 1274. 

Trichina spiralis, 128 1. 

Trichiniasis, 1281; diff. diagn. fr. 

acute rheumatism, 1284; fr. 

cholera, 1284; — — fr. primary 
myositis, 652; fr. ptomaine- 
poisoning, 1284; fr. typhoid 

fever, 1284. 

Trichocephalus dispar, 1280. 

Trichomonas vaginalis, 1264; tr. hom- 
inis, 1264. 

Trifacial neuralgia, 497. 

Tricuspid insufficiency, 1077; mur- 
murs in tricuspid incompetency, 
1078. 

Tricuspid orifice, stenosis of, 1078. 

Trismus neouatorum, 296. 

Trommer's test for sugar, 364. 

Tropical dysentery, 201. 

Trousseau's symptom in tetany, 484. 

Tubercle bacilli, 210. 

Tubercle, diffuse infiltrated, 216. 

Tubercle, miliary, in chronic phthisis, 
228. 

Tubercula dolorosa, 619. 

Tubercular meningitis, 522; diff. diagn. 
fr. cerebro-spinal meningitis, 169; 
fr. simple form, 521; prog- 
nosis, 525; symptoms of, 522; 
therapeutics of, 525. 

Tuberculin in actenomycosis, 311. 

Tuberculosis, 210; acute miliary, 217; 
aetiology, 210; bacillus tuberculo- 
sis, 210; catarrhal affections a pre- I 
disposing cause, 214; hereditary 
transmission of, 212; infection, 
uiodes of, 212; inoculation by ! 
tuberculous matter, 213; milk a 
carrier of infection, 213; of ali- | 



mentary canal, 265 [intestine, 265; 
lips, 265; oesophagus, 265; palate 
and tonsils, 265; pharynx, 265; 
rectum, 266; stomach, 265; tongue, 
265]; of blood-vessels, 26-<; of 
genito-urinary system, 266 [blad- 
der, 267; Fallopian tubes, 267; 
kidneys, 266; prostate gland, 267; 
testicles, 267; uterus, 268]; of 
larynx, 259; of liver, 266; of lym- 
phatic glands, 220; of nervous 
system, 268; of serous membranes, 
263 [pericardium, 263; perito- 
naeum, 263; pleura, 263; tumors 
in periton. cavity, 264]; pulmon- 
ary tuberculosis, 225; the tuber- 
culous process, 215. 

Tuberculosis, acute miliary, 217; men- 
ingeal form, 219; pulmonary form, 
218 [diagnosis, 219; prognosis, 219; 
signs of, 218]; typhoid form, 217 
[diagnosis, 218; diff. diagn. fr. 
typhoid fever, 29, 218; fever of, 
217; symptoms of, 217]; treat- 
ment, 219. 

Tuberculosis, laryngeal, 259; aphonia 
in, 260; cocaine-spray in, 261; 
cough in, 260; diagnosis, 260; 
dysphagia in, 260; iodine in, 261; 
lactic acid treatment of, 261; local 
treatment of, 260; morbid anat- 
omy of, 259; peroxide of hydro- 
gen spray in, 261 symptoms of, 
260; treatment of, 260. 

Tuberculosis of lymphatic glands, 
220; characteristic features of, 
220; clinical forms of, 221; Don- 
kin's description of, 220; general 
lymphadenitis, infrequency of, 
221; prophylaxis, 222; treatment, 
222. 

Tuberculosis, pulmonary, 225. — Class- 
ification of: (a) acute pneumonic 
phthisis, 225 [broncho-pneumonic 
form, 227; pneumonic form, 225]; 
(b) chronic ulcerative phthisis, 
228 [cough in, 231; dyspnoea 
in, 233; elastic tissue in sputum, 



INDEX. 



1329 



232; fever, 233; general symp- 
toms of, 233; haemoptysis, 233; 
laryngeal involvement in, 235; 
morbid anatomy of, 228; pain in, 
231; physical signs of, 235; pneu- 
mothorax in, 235]; (c) fibroid 
phthisis, article on, 23S. — Diagno- 
sis of pulmon. tuberculosis, 238 
[from acute croupous pneumonia, 
240; from bronchiectasis, 240; 
from chronic bronchitis, 239; from 
chronic pleurisy, 239; from pul- 
monary abscess, 240; from pulmo- 
nary gangrene, 240; from pulmon- 
ary syphilis, 240]; invasion of 
lungs by bacilli, 225; prognosis, 
240; treatment of, 241 [climate 
in, 244; diet in, 252; local treat- 
ment, 253; prophylaxis, 241; sea- 
voyages, 245; treatment of cough, 
253; — of diarrhoea, 255; — of 
fever, 254; — of haemorrhage, 255; 
— of indigestion and vomiting, 
256; — of night-sweats, 255; — of 
pain, 254]. 

Tuberculosis, and glanders, 308; and 
pharyngeal ulceration, 716; and 
septicaemia, 184. 

Tumors a cause of intestinal obstruc- 
tion, 854. 

Tumors of brain, 556; diff. diagn. fr. 
abscess of brain, 560; focal symp- 
toms of, 558; forms of, 556; 
headache in, 557; treatment, 560. 

Tumors of spinal cord and its mem- 
branes, 605; anaesthesia dolorosa 
in, 606; diff. fr. transverse myelitis, 
606. 

Tumors of the heart, 1109. 

Tumors of the kidneys, 1295. 

Tussis convulsiva, see whooping 
cough, 156. 

Thermo-anaesthesia in hysteria, 441. 

Typhlitis, see appendicitis, 842. 

Typhoid fever, 19; age in, 19; ambu- 
latory form, 23; bacillus of, 19; 
bathing in, 34; bed-sores in, 32; 
Brand's cold bath, 33; collapse, 
84 



treatment of, 35; contagion in, 
20; diagnosis, 28; diff. diagn. fr. 
acute miliary tuberculosis, 29; 
— — fr. acute periencephalitis, 

399; fr. catarrhal enteritis, 

818; fr. cerebro-spinal men- 
ingitis, 29; — — fr. malignant 
• endocarditis, 1063; — — fr. re- 
mittent fever, 29; fr. t3'phus 

fever, 43; diarrhoea in, 2r, 25; 
diet in, 32; disinfection in, 3:; 
fever in, 21,24; forms of, 27; gas- 
tric symptoms in, 23, 25; haemor- 
rhage in, treatment of, 35; mete- 
orism in, 25; infection, 20; morbid 
anatomy of, 28; nervous symp- 
toms, 22, 26; perforation, 25, 28; 
prognosis, 30; pulmonary symp- 
toms, 23, 26, 29; relapse, 27; 
sequels of, 27; skin-eruptions, 21, 
26; splenic enlargement, 21; stim- 
ulants in, 35; treatment, 30. 

Typhoid fever, abortive form, diff. fr, 
acute gastric catarrh, 758. 

Typhoid state, 22. 

Typhomauia in acute periencephalitis, 
393. 

Typhus abdominalis, see typhoid fever, 

19- 

Typhus fever, 40; broncho-pneumonia 
a sequel of, 43; causation, 40; 
complications , and sequelae, 43; 
contagiousness of, 40; diagnosis, 
43; diff. diagn. fr. cerebro-spinal 

meningitis, 170; fr. measles, 

44; fr. small-pox, 44; 

fr. typhoid fever, 43; eruption of, 
41; fever in, 42; gangrene in, 43; 
mortality in, 43; "mouse-odor" 
in, 41; nervous symptoms of, 42; 
paralysis a sequel of, 43; progno-. 
sis, 43; pulmonary symptoms, 42; 
treatment, 44. 

Tyrotoxicon {Vaughn'), 678. 

Ulcer: duodenal, 815; dysenteric, 200, 
201; gastric, 785; intestinal, S72; 
leprosy, 304, 305; mouth, 693, 



1330 



695; peptic, 7S5; perforating of 

foot, 594; syphilitic, 271, 273; of 

vaccination, 135. 
Ulcerative endocarditis, 1060; diff. 

diagn. fr. pernicious malarial 

fever, 74. 
Ulnar nerve, affections of, 640. 
Uraemia, 1207; a toxaemia, 120S; coma 

in, 1209; convulsions in, 1209; 

deafness in, 1209; diff. diagn. fr. 

pernicious malarial fever, 74; 

gastro-intestinal symptoms in, 

1210; in acute nephritis, 1214; 

uraemic amaurosis, 1209. 
Uraemic coma, 1209; diff. diagn. fr. 

cerebral haemorrhage, 538. • 
Uraemic convulsions, 1209; diff. diagn. 

fr. acute periencephalitis, 400; — 

— fr. epilepsy, 459. 
Uric acid calculus, 1240. 
Uric acid in gout, 346. 
Uric acid diathesis, see lithaemia, 350. 
Uric acid headache, 350. 
Uric acid theory of gout, 347. 
Urinary calculi, 1240. 
Urine, anomalies of secretion, 1193. 
Urine, incontinence of, 1257. 
Urine, suppression of in : acute neph- 
ritis, 1214; cholera, 193; intestinal 

obstruction, 855; scarlet fever, 
105. 
Urobilimuria, 1204. 
Urostealiths, 1240. 



Vaccination, 134. 

Vaccininum in small-pox, 139. 

Vagabond's disease, 1287. 

Vagus, compression of, in rapid heart, 
1114. 

Valsalva's method in aortic aneurism, 
"39- 

Valvular disease of the heart, 1065; 
aortic insufficiency, 1072; aortic 
stenosis, 1076; mitral insufficiency, 
1066; mitral stenosis, 1070; pul- 
monary insufficiency, 1079; pul- 
monary stenosis, 1079; tricuspid 



insufficiency, 1077; tricuspid ste- 
nosis, 1078. 

Valvular disease of the heart, predis- 
posing to malignant endocarditis, 
1060. 

Valvular lesions of heart: broken com- 
pensation in, 1086; cyanosis in, 
10S1 ; compensation, effects of fail- 
ure of, 10S0; course, 10S3; diet in, 
1092; dropsy in, 1081, 1091; dysp- 
noea in, 10S0, 1090; embolism in, 
10S2; heart's action in, 1081; pain 
in, 10S1; stasis in, 1082; treat- 
ment of, 1085. 

Varicella, 141; diagnosis, 142; erup- 
tion, 141; necrosis of tissue in, 
142; symptoms, 141; treatment, 
142. 

Varicose aneurism, 1133. 

Varicose veins, 114S. 

Variola, 129; broncho-pneumonia in, 
133; causation, 129; confluent, 131; 
diagnosis, 133; diff. diagn. fr. 

glanders, 30S; fr. typhus, 44; 

eruption of, 130; forms of, 131, 
132; haemorrhage in, 134; otitis 
media in, 133; "pitting" in, 137; 
prognosis, 133; secondary fever, 
130; specific virus of, 129; stages 
of, 129, 130; symptoms, 129; treat- 
ment, 134: vaccination as a pro- 
phylactic measure, 134. 

Variolinum in small-pox, 139. 

Varix, 1148. 

Varioloid, 132. 

Vaso-motor disorders, 642. 

Vegetations in simple endocarditis, 
105S; in malignant endocarditis, 
1060. 

Veins, inflammation of, 1145; dilata- 
tion of, 1 148. 

Vein-stones, 1146. 

Vena cava superior, perforation by 
aneurism, 1135. 

Ventricles of brain, dilatation of, 522, 
561; haemorrhage into, 531. 

Venous hum in chlorosis, 1157; in tri- 
cuspid insufficiency, 107S. 



1331 



Vertebrae, caries of, see compression 
myelitis, 602. 

Vertigo, 450; aural, 451; cardiac, 450; 
epileptic, 450; essential, 451; 
laryngeal, 451; neurasthenic or 
hysterical, 450; ophthalmic, 451; 
organic or arterio-sclerotic, 450; 
toxaemic, 451. 

Vesicular stomatitis, 692. 

Valvulus, a cause of intestinal obstruc- 
tion, 853. 

Vomicae in phthisis, 229. 

Vomit, black, 49. 

Vomit, coffee-ground, 788, 797. 



Wall-paper, arsenical poisoning from, 

675- 
Warts, post-mortem, 213. 
Washing-out of stomach, 765. 
Wasting palsy, see progressive spinal 

muscular atrophy, 606. 
Weil's disease, 314; analysis of ten 

cases \>y-Jceger, 314; bacillus of, 

315; description of case, by Frey- 

ham, 314. 
Werlhojfs disease, see purpura haem- 

orrhagica, 387. 
WestphaV s symptom, 568. 
White pneumonia of foetus, 280. 
Whooping-cough, 156; complications, 

158; contagion of, 156; diagnosis, 

159; haemorrhages in, 157, 158; 

mortality of, 159; neurotic char- 



acter of, 156; paroxysms of, 157; 
relation to pulmonary tuberculo- 
sis, 159; sequels, 158; stages of, 
157; treatment, 160; "whoop" of, 
157. 

Winter-cough, 982. 

Wool-sorter's disease, 187. 

Word-blindness, 547. 

Word-deafness, 548. 

Wrist-drop, 640; in lead-poisoning, 
669. 

Writers' cramp, 490. 

Wry-neck, 336. 

Xanthine, calculi of, 1240. 
Xerostomia, 704. 

Yellow fever, 49; acclimatization, 50, 
53; aetiology, 49; conditions nec- 
essary for its development, 49; 
diagnosis, 53 diff. diagn. fr. 
dengue fever, 53; — — fr. ma- 
larial fever, 53; fr. pernicious 

malarial fever, 74; — — fr. ty- 
phoid fever, 53; means of convey- 
ance, 49; morbid anatomy, 50; 
prognosis, 53; symptoms, 50; 
treatment, 54; varieties of, 53. 

Yellow jack, see yellow fever, 49. 

Yellow softening of the brain, 542. 

Yeo's dietary in obesity, 686. 

Zona, 499. 




ft 



